G     000  005  486     6 


^ 


-J4 


PRACTICAL  TREATISE 


DIAGNOSIS,  PATHOLOGY,  AND  TfiEATMENT 


DISEASES  OE  THE  HEART. 


BY 


AUSTIN    FLINT,   M.D., 

PROFESSOR  OP  CLINICAL  MEDICINE,  ETC.,  IN  THE  NEW  ORLEANS  SCHOOL  OF  MEDICINE  ; 

VISITING  PHYSICIAN  TO  THE  NEW  ORLEANS  CHARITY  HOSPITAL  ; 

HONORARY  MEMBER  OF  THE  MEDICAL  SOCIETY  OF  VIRGINIA,  OF  THE  KENTUCKY  STATE  MEDICAL  SOCIETY, 

OF  THE  MEDICAL  SOCIETY  OF  RHODE  ISLAND,  OF  THE  PATHOLOGICAL  SOCIETY 

OF  PHILADELPHIA,  ETC. 


PHILADELPHIA: 
BLANCHARD    AND    LEA. 

1859. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1859,  by 

BLANCHARD   AND   LEA, 

in  the  Office  of  the  Clerk  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  Pennsylvania. 


PniLADELPHIA  : 
COLLINS,  PRINTER,  705  JAYXE  STREET. 


Library 

zoo 


TO 


4 


PROFESSORS  HENRY  MILLER,  SAMUEL  D.  GROSS, 

LUNSFORD  P.  YANDELL,  LEWIS  ROGERS,  BENJAMIN  R.  PALMER, 

BENJAMm  SILLIMAiS^  JR.,  J.  LAWRENCE  SMITH, 

T.  G.  RICHARDSON, 

WITH  WHOM 

THE  AUTHOR  WAS  FORMERLY  ASSOCIATED 

■     IN  THE 

UNIVERSITY  OF  LOUISVILLE, 


V 


^  ^Ijig  Uolumc 


IS  RESPECTFULLY  DEDICATED. 


G241f:9 


P  11  E  E  A  C  E . 


In  the  preparation  of  this  volume,  the  aim  has  been  to  meet  the 
wants  of  the  medical  student  and  practitioner  by  the  production  of 
a  work  devoted  exclusively  to  diseases  of  the  heart,  and  treating 
concisely,  but  comprehensively,  of  these  diseases  with  reference  to 
their  diagnosis,  pathology  and  treatment.  Such  a  work,  if  satis- 
factorily executed,  it  is  believed,  can  hardly  fail  to  prove  acceptable, 
in  view  of  the  importance  of  this  class  of  diseases,  the  progress 
made  in  their  investigation  during  the  last  few  years,  and  the 
absence  of  any  extended  text-book,  published  in  this  country, 
having  the  same  scope  and  objects,  since  the  appearance  of  Dr. 
Hope's  treatise  twenty  years  ago.  The  need  of  a  practical  work  on 
diseases  of  the  heart  is  so  apparent,  that  the  present  efibrt  requires 
no  apology;  and  if  not  successful,  the  fault  must  be  imputed  to  the 
performance  rather  than  to  the  undertaking.  The  author  ventures 
to  hope,  in  submitting  this  volume  to  the  profession,  that  it  may 
be  found,  in  some  measure  at  least,  to  supply  a  desideratum,  the 
existence  of  which  must  have  been  felt  by  many  practising  phy- 
sicians, and,  more  especially,  by  medical  teachers  and  their  pupils. 

It  will  be  observed  that  the  arrangement  of  subjects  in  this  work 
differs  from  that  generally  adopted.  As  regards  the  order  in  which 
the  different  diseases  are  considered,  the  plan  usually  pursued  may 
be  said  to  be  synthetical,  inflammatory  affections  being  taken  up 
first,  and  afterward  the  lesions  which  are,  to  a  considerable  extent, 
results  of  inflammation.  A  method  which  may  be  distinguished  as 
analytical,  has  appeared  to  the  author  preferable.  Pursuing  this 
method,  the  work  commences  with  the  consideration  of  organic 
affections.  Enlargement  of  the  heart,  occurring  often  consecutively 
to  other  lesions,  takes  precedence.  To  this  subject  the  first  chapter 
is  devoted.  Lesions  affecting  the  walls  of  the  heart  naturally  come 
next  in  order.  These  constitute  the  subject  of  the  second  chapter. 
Valvular  lesions  are  then  considered,  occupying  two  chapters,  and 


VI  PREFACE. 

a  chapter  is  devoted  to  congenital  malformations.  Several  affec- 
tions which  are  incidental  to  diseases  of  the  heart,  are  treated  of  in 
a  distinct  chapter.  Then  follow  the  inflammatory  affections,  and, 
afterward,  functional  disorders  of  the  heart,  three  chapters  being 
allotted  to  these  classes  of  disease.  Finally,  thoracic  aneurisms, 
which  claim  consideration  in  connection  with  diseases  of  the  heart, 
are  made  the  subject  of  the  concluding  chapter. 

In  writing  the  book,  the  end  which  the  author  has  kept  steadily 
in  view  is,  a  fair  and  full  exposition  of  our  present  knowledge 
of  the  diagnosis,  pathology  and  treatment  of  diseases  of  the  heart. 
Eecognizing  clinical  study  as  the  great  source  of  this  knowledge, 
he  has  endeavored  to  make  the  cases  reported  by  trustworthy 
observers,  together  with  his  own  recorded  experience,  the  basis  of 
the  work.  Having  long  been  in  the  habit  of  making  records  at 
the  bedside,  and  having  given  for  several  years  particular  attention 
to  diseases  of  the  heart,  he  has  accumulated  notes  of  about  two 
hundred  cases  of  the  various  cardiac  affections.  The  results  of  an 
analysis  of  these  cases  have  been  before  him  during  the  composition 
of  the  work.  As  a  preliminary  step,  also,  over  one  hundred  fatal 
cases  gathered  from  different  authors,  chiefly  from  tbe  works  of 
Hope,  Stokes,  Andry  and  Blakiston,  were  subjected  to  similar 
analysis.  On  the  data  thus  obtained  have  been  based,  in  a  great 
measure,  the  statements  and  opinions  which  the  work  contains, 
endeavoring,  however,  not  to  introduce  details  and  statistics  to  an 
extent  to  prove  repulsive  or  fatiguing  to  the  reader.  But  although 
it  may  be  claimed  in  behalf  of  the  work  that  it  is  something  more 
than  a  compilation,  not  to  have  studied  closely  the  literature  of  the 
subject,  would  have  been  an  injustice  alike  to  it,  and  to  those  by 
whose  labors  this  department  of  practical  medicine  owes  its  present 
development.  Of  the  authors  to  whom  acknowledgments  are  due, 
the  names  of  Bouillaud,  Hope.  Stokes,  Walshe,  Andry,  Forget  and 
Bellingham  are  to  be  especially  mentioned.  Eeferences  to  these 
and  others  will  frequently  occur  in  the  following  pages.  The  author 
has  aimed  to  prepare  a  practical  treatise,  and  he  has  therefore 
avoided,  or  dismissed  with  as  much  brevity  as  possible,  speculative 
opinions  and  mooted  questions  involving  discussions  which  would 
occupy  space  to  the  disparagement  of  matters  relating  more  directly 
to  medical  practice.  It  may  seem,  nevertheless,  to  some,  that  the 
volume  is  out  of  proportion  to  the  field  of  practical  medicine  to 
which  it  is  restricted ;  but  it  is  hoped  there  will  be  no  reason  to 
complain  of  a  redundancy  either  in  style  or  matter,  and  that  the 


PREFACE,  VU 

reader  will  be  led  to  attribute  the  size  of  the  book  to  the  progress 
of  knowledge  pertaining  to  diseases  of  the  heart,  together  with 
their  intrinsic  claims  on  the  attention  of  the  student  and  practi- 
tioner. 

A  liberal  share  of  the  work  is  devoted  to  physical  signs.  But  a 
just  estin:iate  of  their  practical  importance  will  obviate  any  objection 
on  this  score.  It  is  mainly  owing  to  physical  exploration  that  the 
study  of  these  diseases  has  been  prosecuted  within  the  past  few 
years  with  such  remarkable  success.  Here,  as  in  other  classes  of 
affections,  the  knowledge  to  be  derived  from  clinical  observation  is 
increased  in  proportion  to  improvement  in  diagnosis,  and  it  is 
evident  that  diseases  cannot  be  judiciously  treated  unless  correctly 
discriminated.  The  discrimination  of  diseases  is  confessedly  the 
portion  of  our  art  which  involves  the  most  difficulty  and  calls 
for  the  greatest  amount  of  skill.  Hence,  it  is  especially  under 
this  practical  aspect  that  diseases  in  general  claim  careful  and 
extended  consideration.  This  remark,  certainly,  is  not  less  appli- 
cable to  diseases  of  the  heart  than  to  other  nosological  divisions. 
And  the  diagnosis  of  cardiac  diseases  is  for  the  most  part  based  on 
the  physical  signs.  It  is,  therefore,  by  no  means  solely  because 
these  are  interesting,  but  on  account  of  their  great  practical  im- 
portance, that  so  much  space  has  been  accorded  to  them  in  the 
present  treatise.  In  treating  of  the  physical  signs,  it  was  necessary 
to  introduce  some  matter  belonging  properly  to  anatomy  and  phy- 
siology, viz.,  the  relations  of  the  heart  to  the  walls  of  the  chest  and 
the  adjacent  viscera,  the  movements  of  the  organ,  and  the  normal 
heart-sounds.  With  reference  to  the  movements  and  sounds  of  the 
heart,  the  author  has  been  led  by  examinations  of  the  healthy  chest 
to  conclusions  which  appear  to  have  important  practical  bearings. 
The  abnormal  modifications  of  the  heart-sounds  have  hitherto 
scarcely  received  sufficient  attention.  More  importance  is  attached 
to  them  as  diagnostic  signs,  and  they  are  considered  mo.re  fully  in 
this  work  than  in  any  other  on  the  diseases  of  the  heart  with  whicb 
the  author  is  acquainted.  As  regards  the  sounds  of  the  heart  in 
health  and  disease,  some  original  views  are  introduced,  which  have 
entered  into  a  previous  publication.' 

In  thus  setting  forth,  briefly,  the  plan  and  objects  of  the  work, 
the  author  assumes  only  to  have  spared  no  pains  to  render  it 

'  On  the  Clinical  Study  of  the  Heart-Sounds  in  Health  and  Disease. — Transac- 
tions of  the  American  Medical  Association  for  1858. 


VUl  PREFACE. 

acceptable  to  the  profession.  All  who  have  engaged  in  similar 
undertakings  amidst  the  cares  and  distractions  of  active  medical 
practice,  will  appreciate  the  diflBculty  of  the  task.  But  the  time 
and  labor  which  the  author  has  bestowed  upon  it,  will  be  more 
than  requited  by  the  approval  of  his  medical  brethren ;  and  he  is 
encouraged  to  hope  for  this  reward  by  the  favor  with  which  his 
previous  contributions  to  practical  medicine  have  been  received. 


The  author  would  express  his  thanks  to  Prof.  John  C.  Dalton,  Jr., 
for  the  two  illustrations  which  form  the  frontispiece,  and  for  other 
friendly  offices ;  also,  to  Dr.  Austin  W.  Nichols,  formerly  assistant 
to  the  chair  of  clinical  medicine  in  the  University  of  Buffalo,  for 
his  valuable  assistance  in  collecting  materials  for  the  preparation 
of  the  work. 

New  York,  September,  1859. 


CONTENTS. 


I 


CHAPTER   I. 

ENLARGEMENT  OF  THE  HEART. 

Definition  and  varieties  of  liypertrophy  and  dilatation 

Normal  dimensions  and  weight  of  the  heart 

Enlargement  by  hypertrophy  ..... 

Concentric  hypertrophy        ..... 

Symptoms  and  pathological  effects  of  hypertrophy 
Normal  situation  and  anatomical  relations  of  the  heart      .     • 
Physical  signs  of  hypertrophy  obtained  by  percussion 
Normal  situation  and  extent  of  the  apex-beat 
Mechanism  of  the  heart's  impulse    .... 

Altered  situation  and  extent  of  the  apex-beat  in  enlargement 
Increased  force  of  the  apex-beat  and  abnormal  impulses  in  hyper 
trophy        ....... 

Clinical  study  of  the  heart-sounds  in  health 

Abnormal  modifications  of  the  heart-sounds  in  hypertrophy 

Increased  size  of  the  prsecordia  and  abnormal  movements  in  en 

largement  as  determined  by  inspection     . 
Increased  size  of  the  chest  as  determined  by  mensuration 
Diagnosis  of  enlargement  of  the  heart  and  hypertrophy     . 
Summary  of  the  physical  signs  of  enlargement  of  the  heart 
Summary  of  the  physical  signs   distinctive   of  enlargement  by 
hypertrophy  ...... 

Treatment  of  hypertrophy    ..... 

Enlargement  by  dilatation    ...... 

Pathological  process,  etc.,  involved  in  the  production  of  dilatation 
Symptoms  and  pathological  effects  of  dilatation     . 
Physical  signs  of  dilatation  .... 

Diagnosis  of  dilatation  ..... 

Summary  of  the   physical  signs  distinctive   of  enlargement  by 
dilatation    ....... 

Treatment  of  dilatation        ..... 


PAGE 

17 
19 
23 
31 
33 
35 
40 
45 
47 
49 

50 
58 
63 

67 
68 
69 
70 

71 

72 
77 
78 
80 
82 
84 

84 
85 


COXTENTS. 


CHAPTER   II. 


LESIONS,  EXCLUSIVE  OF  ENLARGEMENT,  AFFECTING  THE  WALLS  OF 

HEART. 


THE 


Atrophy  with  diminished  bulk  of  the  heart 

Fatty  growth  and  degeneration        .... 

Pathological  character  and  antecedent  morbid  conditions 

Symptoms  and  pathological  effects 

Physical  signs  and  diagnosis 

Treatment 
Softening  of  the  heart 

Symptoms  and  pathological  effects 

Physical  signs 

Treatment 
Induration  of  the  heart 
Cardiac  aneurism 
Rupture  of  the  heart 


90 

92 

94 

99 

101 

106 

107 

108 

110 

111 

112 

115 


CHAPTER   III. 


LESIONS  AFFECTING  THE  VALVES  AND  ORIFICES  OF  THE  HEART. 


Aortic  and  mitral  lesions      ....... 

Symptoms  and  secondary  pathological  effects  referable  to  the  heart 

Pain  and  palpitation  ..... 

Pulse  ....... 

Turgescence  of  veins  and  venous  pulsation 
Symptoms  and  pathological  effects  referable  to  the  circulation 

Cardiac  dropsy  ..... 

Arterial  obstruction  by  fibrinous  deposits  detached  from 

the  valves  or  orifices — Embolia 

Symptoms  and  pathological  effects  referable  to  the  respiratory 

system        .  .  -  .  .  .  . 

Dyspnoja         ...... 

H  hemoptysis    ...... 

Pulmonary  oedema,  etc.  .... 

Symptoms  and  pathological  effects  referable  to  the  nervous  system 

Apoplexy        ...... 

Sleep  and  mental  condition    .... 
Symptoms  and  pathological  effects  referable  to  the  digestive  sys 
tcm  and  nutrition  ...... 

Portal  congestion       ..... 


120 
127 
133 
135 
142 
147 
147 

151 

154 
156 
159 
160 
163 
165 
167 

168 
169 


CONTENTS. 


XI 


Hemorrliages  ..... 

Nutrition        ...... 

Symptoms  and  pathological  effects  referable  to  the  genito-urinary 
system         ....... 

Bright's  disease  ..... 

Symptoms  and  pathological  effects  referable  to  the  countenance 
and  external  appearance  of  the  body 


PAGE 
171 
171 

172 
173 

174 


CHAPTER   lY. 


PHYSICAL  SIGNS,  DIAGNOSIS,  AND  TREATMENT  OF  VALVULAR  LESIONS. 

Endocardial  or  valvular  murmurs    ......  177 

Classification  of  organic  murmurs    .....  18.o 

Mitral  direct  or  diastolic  murmur     .....  186 

Mitral  regurgitant  or  systolic  murmur          ....  188 

Aortic  direct  or  systolic  murmur     .....  190 

Aortic  regurgitant  or  diastolic  murmur        ....  191 

Localization  of  systolic  murmurs     .....  194 

Localization  of  diastolic  murmurs    ...             .             .             .  197 

Recapitulation  of  points  involved  in  the  localization  of  systolic 

and  diastolic  murmurs        ......  199 

Pathological  import  of  organic  endocardial  murmurs          .             .  200 

Inorganic  murmurs    .......  202 

Abnormal  modifications  of  the  heart-sounds  in  cases  of  valvular  lesions  206 

Diagnostic  characters  of  lesions  affecting  the  mitral,  aortic,  tricuspid, 

and  pulmonic  valves  or  orifices    ......  209 

Diagnostic  characters  of  mitral  lesions        ....  210 

Diagnostic  characters  of  aortic  lesions        ....  211 

Diagnostic  characters  of  tricuspid  lesions   ....  213 

Diagnostic  characters  of  pulmonic  lesions  ....  21.5 

Treatment  of  valvular  lesions          ......  217 


CHAPTER   V. 


CONGENITAL  AHSPLACEMENTS,  DEFECTS,  AND  MALFORMATIONS  OF  THE 

HEART. 

Congenital  misplacements    .......  231 

Deficiency  of  the  pericardium         ......  232 

Malformations  .  .  .  ...  .  .  .  232 

Cyanosis  ........  238 


Xll 


CONTENTS. 


CHAPTER   YI. 


CERTAIN  AFFECTIONS  INCIDENTAL  TO  ORGANIC  DISEASES  OF  THE 

HEART. 

Formation  of  clots  and  fibrinous  coagula  within  the  cavities  of  the  heart 
Polypi  of  the  heart ........ 

Angina  pectoris        ........ 

Enlargement  of  the  thyroid  body  and  prominence  of  the  eyes 
Reduplication  of  the  heart-sounds  ...... 


PAGE 

245 
253 
2.54 
267 
274 


CHAPTER    VII. 


INFLAMMATORY  AFFECTIONS  OF  THE  HEART — PERICARDITIS. 


Acute  pericarditis    .... 

Anatomical  characters 

Pathological  relations  and  causation 
Connection  with  rheumatism 
Connection  with  Bright's  disease 
Connection  with  scurvy,  etc. 

Symptoms      .... 

Symptoms  referable  to  the  heart 
Symptoms  referable  to  the  circulation 
Symptoms  referable  to  the  respiratory  system 
Symptoms  referable  to  the  nervous  system 

Physical  signs  .... 

Signs  furnished  by  percussion 
Signs  furnished  by  auscultation 
Signs  furnished  by  palpation 
Signs  furnished  by  inspection 
Signs  furnished  by  mensuration 

Summary  of  the  physical  signs  of  acute  pericarditi 

Diagnosis 

Prognosis 

Treatment 
Subacute  and  chronic  pericarditis  . 
Pneumo-pericardium  and  pneumo-pericarditis 
Pericardial  adhesions 


283 
283 
290 
291 
292 
295 
297 
298 
300 
303 
305 
312 
312 
316 
326 
328 
329 
329 
331 
334 
337 
351 
357 
360 


CONTENTS. 


XUl 


CHAPTER    YIII. 

INFLAMMATORY  AFFECTIONS  OF  THE  HEART — ENDOCARDITIS- 
MYOCARDITIS. 


PAGE 

Endocarditis   .........      371 

Anatomical  characters 

371 

Pathological  relations  and  causation 

377 

Connection  with  rheumatism 

377 

Connection  with  Bright's  disease 

379 

Artificial  production  of 

381 

Formation  of  coagula,  etc. 

383 

Symptoms 

• 

384 

Physical  signs 

385 

Diagnosis 

390 

Prognosis 

392 

Treatment     . 

393 

Myocarditis  .... 

399 

CHAPTER   IX. 


FUNCTIONAL  DISORDER  OP  THE  HEART. 


Varieties  of  functional  disorder 

403 

Pathological  relations  and  causation 

405 

Connection  with  plethora  and  ansemia 

405 

Connection  with  hysteria,  etc. 

406 

Connection  with  dyspepsia  . 

408 

Connection  with  gout 

408 

Symptoms     .... 

409 

Physical  signs 

410 

Signs  furnished  by  percussion 

410 

Signs  furnished  by  palpation 

411 

Signs  furnished  by  auscultation 

412 

Diagnosis      .... 

415 

Prognosis      .... 

421 

Treatment     . 

422 

XIV 


CONTEXTS. 


CHAPTER   X. 


DISEASES  OF  THE  AORTA — THORACIC  ANEURISMS. 


Inflammation  of  the  aorta  .... 
Morbid  deposit  on  the  surface  of  the  lining  membrane 
Atheroma  and  calcareous  degeneration 
Dilatation  of  the  aorta 
Thoracic  aneurisms  . 

Varieties  of  aneurism 

Anatomical  relations  of  thoracic  aneurisms 

Formation  and  causes 

Terminations    • 

Symptoms 

Dyspnoea 
Aphonia 
Dysphagia 
Lividity,  etc. 
Pulse 
Pain    . 

Pai'aplegia  and  hemiplegia    . 
Physical  signs 

Signs  furnished  by  palpation 
Signs  furnished  by  percussion 
Signs  furnished  by  auscultation 
Diagnosis       .... 
Treatment     .... 


PAGE 

429 
432 
432 
435 
436 
437 
439 
441 
442 
443 
444 
445 
446 
447 
447 
448 
449 
450 
450 
453 
454 
457 
461 


DESCRIPTION  OF  THE  PLATE 

IN    FRONT    OF    THE    TITLE. 

Fig.  1  illustrates  the  relations  of  the  heart  to  the  thoracic  parietes.  The 
letters  a,  b,  c,  etc.,  indicate  the  ribs.  The  figures  1,  2,  3,  etc.,  mark  the  inter- 
costal spaces.  The  vertical  line  denotes  the  median  line.  The  right  angled 
triangle  extending  over  a  portion  of  the  surface  of  the  heart,  represents  the 
"  superficial  cardiac  region"  as  delineated  on  the  chest  with  sufficient  accuracy 
for  practical  purposes.  The  cross  on  the  fourth  rib  shows  the  situation  of  the 
nipple.  The  relations  of  the  ventricles,  auricles,  apex  of  the  heart,  aorta,  and 
pulmonary  artery,  to  the  ribs  and  intercostal  spaces,  the  median  line  and  the 
nipple,  are  accurately  indicated. 

Fig.  2  illustrates  the  relations  of  the  heart  to  the  pulmonary  organs,  liver, 
and  stomach.  The  quadrangular  space  in  which  the  heart  is  uncovered  by 
lung  is  the  "  superficial  cardiac  region,"  represented  more  accurately  than  in 
Fig.  1.  The  relative  situations  of  the  left  lobe  of  the  liver,  the  stomach,  and 
inferior  border  of  the  heart,  are  correctly  represented. 


DISEASES  OF  THE  HEART. 


CHAPTER   I. 

ENLARGEMENT    OF    THE    HEART. 

Definition  and  varieties  of  hypertrophy  and  dilatation — Normal  dimensions  and  weight 
of  heart — Enlargement  by  hypertrophy — Concentric  hypertrophy — Symptoms  and  patho- 
logical effects  of  hypertrophy — Physical  signs  and  diagnosis  of  enlargement  and  hyper- 
trophy— Situation  and  anatomical  relations  of  the  heart  in  health — Alterations  in  degree 
and  extent  of  dulnesa  on  percussion  in  hypertrophy — Altered  situation  and  extent  of  the 
apex-beat,  and  abnormal  force  of  impulse  in  hypertrophy,  as  determined  by  palpation — 
Mechanism  of  the  heart's  impulse — Abnormal  modifications  of  the  heart-sounds — Dimi- 
nished extent  and  degree  of  the  respiratory  murmur  and  vocal  resonance  within  the 
prajcordia  in  hypertrophy,  as  determined  by  auscultation — Results  of  the  clinical  study 
of  the  heart-sounds  in  health — Enlargement  of  the  prajcordia  and  abnormal  movements 
in  hypertrophy,  as  determined  by  inspection — Increased  size  of  the  chest,  as  determined 
by  mensuration — Summary  of  the  physical  signs  of  enlargement  of  the  heart — Summary 
of  the  physical  signs  distinctive  of  enlargement  by  hypertrophy — Treatment  of  hyper- 
trophy— Enlargement  by  dilatation — Symptoms  and  p)athological  effects  of  dilatation — 
Physical  signs  and  diagnosis  of  dilatation — Summary  of  the  physical  signs  distinctive  of 
enlargement  by  dilatation — Treatment  of  dilatation. 

Enlargement  of  the  heart  is  a  term  wbicli  embraces  aboor- 
mal  increase  in  the  volume  of  this  organ,  in  its  weight,  or,  as  is 
commonly  the  case,  increase  both  in  weight  and  volume.  Aug 
mentation  of  the  volume  of  the  heart,  and  of  its  weight,  gives  rise  to 
different  forms  of  enlargement,  which,  although  usually  associated, 
may  exist  each  independently  of  the  other.  The  heart  may  exceed 
the  limits  of  health  as  regards  weight,  in  consequence  of  an  increased 
thickness  of  its  walls,  the  normal  bulk  being  retained.  This  may 
and  does  occur,  although,  in  the  vast  majority  of  the  cases  in  which 
the  weight  is  augmented,  the  volume  exceeds  the  healthy  limits. 
On  the. other  hand,  the  bulk  of  the  heart  may  be  abnormally  great, 
the  cavities  being  enlarged,  and  the  thickness  of  the  walls  so  far 
diminished,  that  the  normal  weight   is   retained.     This   form  of 

9, 


18  ENLARGEMENT    OF    THE    HEART. 

enlargement  is  also  of  very  rare  occurrence,  the  organ  generally 
increasing  in  weight  Avhen  its  bulk  is  greater  than  in  health. 
Abnormal  increase  of  the  heart  in  weight,  due  to  morbid  thickness 
of  the  walls  of  the  organ,  constitutes  the  condition  called  hyper- 
trophy.  Abnormal  increase  of  the  heart  in  volume,  due  to  the 
morbid  size  of  its  cavities,  constitutes  the  condition  called  dilatation. 
These  names,  hypertrophy  and  dilatation,  thus  denote  different 
forms  of  enlargement  of  the  heart,  presented  sometimes  separately, 
but  usually  together.  Each  of  these  two  forms  of  enlargement  are 
subdivided  by  writers  into  several  varieties,  the  subdivisions  being 
based  on  well-marked  and  important  distinctions.  Hypertrophy 
difi'ers  in  different  cases,  according  to  the  condition  of  the  cavities, 
as  regards  size,  associated  with  it.  It  exists  in  some  cases  without 
any  alteration  of  the  cavities,  the  latter  remaining  normal.  This 
variety  is  called  pure  or  simple  hypertrophy.  The  cavities  may  be 
diminished  in  size  below  the  limits  of  health.  This  must  be 
admitted  as  a  variety  of  hypertrophy,  although  its  existence  is 
denied  by  some.  It  has  been  distinguished  as  concentric  hypertrophy, 
or  hypertrophy  with  contractioyi.  The  variety  occurring  much  more 
frequently  than  the  others,  in  fact,  that  which  exists  in  the  vast 
majority  of  the  cases  in  which  the  heart  is  hypertrophied,  is 
characterized  by  the  coexistence  of  dilatation  to  a  greater  or  less 
extent.  This  variety  is  called  eccentric  htjpertrophy,  or  hypertrophy 
icith  dilatation.  The  other  form  of  enlargement,  viz.,  dilatation, 
differs  in  different  cases,  according  to  the  condition,  as  regards 
thickness,  of  the  walls  of  the  heart.  Dilatation  exists  in  some 
cases,  the  walls  retaining  their  normal  thickness.  This  is  called 
pure  or  simple  dilatation.  It  is  obvious,  however,  that,  in  propor- 
tion to  the  dilatation,  the  heart  is  hypertrophied,  assuming  the 
walls  to  preserve  their  normal  thickness,  inasmuch  as  the  mass  of 
muscular  structure  and  the  weight  of  the  organ  under  these  circum- 
stances must  be  increased.  In  other  cases  in  which  the  capacity  of 
the  cavities  is  increased,  the  thickness  of  the  walls  is  diminished. 
In  this  variety,  the  weight  of  the  heart  may  not  exceed,  and  may 
even  fall  below,  that  of  health.  This  is  distinguished  as  dilatation 
with  attenuated  walls,  or  attenuated  dilataiio7i.^  The  third  variety  of 
dilatation  occurs  with  far  greater  frequency  than  either  of  the  other 

'  In  the  rare  instances  in  wliicli  the  walls  are  so  attenuated  that  the  weight  of 
the  heart  falls  below  the  limits  of  health,  the  condition  is  one  of  atrophy.  There 
is,  however,  no  practical  advantage  in  constituting  this  a  distinct  variety  of 
enlargement. 


DIFFERENT    FORMS    OF    ENLARGEMENT.  19 

varieties,  and  is  cliaracterized  by  the  coexistence  of  hypertrophy, 
well  marked,  the  dilatation,  however,  being  predominant. 

These  subdivisions,  although  based  on  distinctions  which  are  real 
and  important,  are  somewhat  complicated  and  embarrassing  to  the 
student.  They  are  consistent  with  the  different  morbid  conditions 
of  the  heart,  as  determined  by  examinations  after  death ;  but  they 
are  not  accompanied  by  diagnostic  criteria,  by  means  of  which  they 
may  always  be  discriminated  at  the  bedside  during  life.  A  simpler 
arrangement  is  clinically  more  available,  and  suffices  for  all  prac- 
tical purposes.  We  may  distribute  all  cases  of  enlargement  of  the 
heart  into  two  classes,  viz.,  1st.  Enlargement  by  hypertrophy;  and 
2d.  Enlargement  by  dilatation.  These  classes  will  include,  respect- 
ively, cases  in  which  the  hypertrophy  and  the  dilatation  are  either 
simple  or  predominant.  In  cases  of  "  enlargement  by  hypertrophy," 
the  cavities  may  or  may  not  exceed  their  normal  capacity.  Cases 
in  which  the  cavities  are  diminished  will  also  fall  in  this  class.  If 
the  hypertrophy  be  neither  simple  nor  concentric^  it  is  included  in 
this  class  whenever  it  is  proportionately  greater  than  the  coexisting 
dilatation.  The  symptoms  and  signs  enable  the  diagnostician  to 
determine,  often  with  positiveness,  the  existence  of  hypertrophy, 
which  is  either  simple,  or  predominant  over  a  coexisting  dilatation ; 
but  to  discriminate  between  the  cases  in  which  the  hypertrophy  is 
simple  and  those  in  which  it  predominates  over  coexisting  dilata- 
tion, is  a  problem  in  diagnosis  by  no  means  easily  solved.  So  in 
cases  of  "  enlargement  by  dilatation,"  the  amount  of  muscular  struc- 
ture may  or  may  not  exceed  the  limits  of  health.  The  diagnostic 
criteria  of  predominant  dilatation  are  often  sufficiently  positive; 
but  it  is  far  less  easy  to  decide  whether  the  dilatation  be  accom- 
panied with  hypertrophy  or  attenuation.  Moreover,  as  regards 
prognosis  and  treatment,  after  the  existence  and  degree  of  enlarge- 
ment are  ascertained,  it  is  enough  to  determine  which  form  of 
enlargement  predominates,  hypertrophy  or  dilatation.  In  treating 
of  enlargement  of  the  heart,  I  shall  follow  the  simple  classification 
just  indicated. 

As  a  point  of  departure  for  the  study  of  those  afiections  of  the 
heart  which  consist  of  abnormal  deviations  in  size,  its  normal 
dimensions  and  weight  are  to  be  considered.  The  healthy  stand- 
ards in  these  respects  are  obtained  by  measuring  and  weighing  a 
sufficiently  large  number  of  hearts  presumed  to  be  devoid  of  disease. 
As  regards  measurements,  the  diameters  and  the  thickness  of  the 
walls  are  the  points  which  have  reference  to  the  afiections  to  be 


20  ENLARGEMENT    OF    THE    HEART. 

treated  of  in  this  chapter.  The  dimensions  of  the  orifices  and 
valves  will  be  considered  in  connection  with  lesions  in  this  situa- 
tion. The  researches  of  Bizot  and  others  show  that  the  volume  of 
the  heart  varies  according  to  sex  and  age.  It  is  somewhat  gredter 
in  the  male  than  in  the  female,  and  it  increases  slowly,  but  pro- 
gressively, from  infancy  to  old  age.  It  is  to  be  observed  that 
diametrical  measurements  after  death  are  liable  to  be  affected  by 
incidental  circumstances,  by  which  they  are  rendered  only  approxi- 
matively  correct.  The  degree  of  contraction  varies  according  to 
the  quantity  of  blood  which  the  cavities  contain  at  the  time  of 
death.  Observations  show  that  when  death  occurs  from  hemor- 
rhage and  from  diseases  attended  by  rapid  loss  of  fluids,  the 
cavities  are  much  diminished,  and  the  volume  proportionately 
small ;  while,  on  the  other  hand,  if  the  cavities  are  distended  with 
blood,  they  are  dilated,  and  the  volume  increased  in  proportion. 
In  consequence  of  these  variations,  the  measurements  of  the  entire 
organ,  made  by  means  of  careful  percussion  and  auscultation 
during  life,  are  as  reliable,  if  not  more  so,  than  those  made  in  the 
dead  subject.  In  Bizot's  tables  are  exhibited  the  mean  measure- 
ments of  the  length,  breadth,  and  depth  of  the  heart  as  a  whole,  and 
of  the  two  ventricles,  respectively,  in  the  two  sexes  at  different  ages. 
As  standards  for  comparison,  with  reference  to  the  existence  of 
abnormal  enlargement,  it  is  sufficient  to  take  into  view  the  vertical 
and  transverse  diameters,  the  contents  of  the  cavities  having  been 
removed.  And  it  suffices  to  express  the  normal  averages  in  figures 
approximating  to  the  exact  results  obtained  by  taking  the  mean  of 
measurements,  disregarding  fractional  amounts,  which  the  student 
cannot  be  expected  to  remember.  Moreover,  the  results  obtained 
by  different  observers  present  considerable  variation,  which,  in 
view  of  the  facts  just  stated,  might  be  expected.  Adopting,  as  a 
basis,  the  measurements  by  Bizot  and  others,  it  is  sufficiently  exact 
to  say  that  the  average  length  of  the  heart,  measured  from  apex  to 
base  on  its  anterior  surface,  in  the  male,  between  the  ages  of  thirty 
and  fifty,  is  about  four  inches,  being  in  the  female  somewhat  less ; 
and  that  the  width,  measured  at  its  widest  part,  in  the  male,  is  a 
small  fraction  over  four  inches,  being  somewhat  less  in  the  female.' 

'  Farther  details  witli  regard  to  measurements  of  volume  are  dispensed  with  as 
practically  not  important  in  this  connection.  Bizot's  extensive  and  elaborate 
researches,  which  will  be  again  referred  to,  were  published  in  the  Mtmoires  de  la 
Soci'jte  JUdicah  d^  Observation  de  Paris,  1836.  For  a  summary  of  his  results 
relating  to  the  above  points  and  others,  the  reader  is  referred  to  Hope  on  Diseases 


NOEMAL    DIMENSIONS    AND    WEIGHT    OF    THE    HEAET.     21 

The  general  remarks  just  made  with  reference  to  the  normal 
volume  of  the  heart,  are  also  applicable  to  the  thickness  of  the 
walls ;  the  thickness  is  greater,  as  a  rule,  in  males  than  in  females, 
and  it  increases  with  age.  It  varies,  also,  according  to  the  contrac- 
tion of  the  heart  at  the  time  of  death,  dependent  on  the  amount  of 
blood  contained  within  the  cavities,  and  other  circumstances. 
Hence,  measurements  here,  as  with  respect  to  the  diameters,  in  a  col- 
lection of  hearts,  furnish  results  which  are  only  approximations  to 
correctness.  Pursuing  the  same  course  as  in  expressing  the  normal 
standard  of  volume,  it  is  approaching  near  enough  to  exactness  to 
say  that  the  wall  of  the  left  ventricle,  at  its  thickest  portion,  in 
middle  life,  is  not  far  from  half  an  inch  in  the  male,  and  in  the 
female  a  fraction  less.  The  thickest  part  of  this  ventricle  is  near 
its  centre.  The  thickness  is  less  near  the  base,  and  still  less  at 
the  apex.  The  wall  of  the  right  ventricle,  at  its  thickest  portion, 
is  a  little  over  one-sixth  of  an  inch,  in  the  male,  and  in  the  female 
somewhat  less.  The  thickest  part  of  this  ventricle  is  near  the  base, 
and  the  thinnest  near  the  apex.  The  relative  thickness  of  the  two 
ventricles  is,  thus,  in  the  ratio  of  3  to  1.  The  average  thickness 
of  the  right  auricle  is  estimated  to  be  about  a  twelfth  of  an  inch, 
and  of  the  left  auricle  somewhat  greater. 

The  average  normal  dimensions  of  the  heart  as  a  whole,  and  of 
different  parts  of  the  organ,  are  important  as  standards  of  com- 
parison by  which  to  estimate  abnormal  changes.  Their  importance 
in  this  respect,  however,  is  less  than  might,  at  first  viev/,  be  ima- 
gined. The  deviations  from  these  standards,  which  are  embraced 
within  the  limits  of  health,  are  to  be  taken  into  account.  The 
range  of  normal  variation,  as  regards  the  volume  of  the  heart  and 
thickness  of  its  walls,  is  considerable.  An  addition  of  an  inch  or 
more  to  the  vertical  and  transverse  diameters  may  not  be  abnormal. 
So,  a  proportionate  amount  of  increased  thickness  of  the  walls  of 
the  ventricles  may  be  within  healthy  limits.  To  determine  the 
line  of  demarcation  between  normal  and  abnormal  deviations,  is 
more  difficult  than  to  ascertain  averages.  It  is  not  easy  to  fix  a 
maximum  and  a  minimum,  beyond  which  the  condition  is  always 

of  the  Heart,  Am.  ed.,  edited  by  Pennock  ;  to  the  work  by  Dr.  Stokes  on  Diseases  of 
the  Heart  and  Aorta;  and  to  Bellingham  on  Diseases  of  the  Heart,  Part  I.,  Dub.  ed. 
For  results  of  measurements  by  Ranking,  Gross,  and  others,  Gross's  Path.  Anat., 
third  edition,  and  Dunglison's  Physiology,  eighth  edition,  may  be  consulted  ;  see 
also  Traite  Clinique  des  Maladies  du  Cmur,  par  J.  Bouillaiid,  which  contains  mea- 
surements by  himself  and  strictures  on  the  researches  of  Bizot. 


22     ■  EI^'LARGEMEXT    OF    THE    HEART. 

morbid.  And  even  were  the  boundaries  definitely  fixed,  it  might 
still  be  a  matter  of  doubt  in  some  individual  cases  in  which  the 
limits  were  not  exceeded,  whether  the  condition  was  not  abnormal. 
Enlargement  of  the  heart  sufficient  to  be  of  much  pathological 
importance,  is  generall}''  so  well  marked  that  its  existence  does  not 
admit  of  doubt.  Practically,  therefore,  the  want  of  precise  data 
for  defining  rigorously  the  confines  of  morbid  anatomy,  does  not 
lead  to  serious  inconvenience.  These  remarks  are  applicable,  not 
only  to  the  dimensions  of  the  heart  already  considered,  but,  equally, 
to  the  capacity  of  its  cavities  and  to  its  weight. 

The  cavities  of  the  heart  are  not  readily  measured.  Their  capa- 
city varies,  irrespective  of  intrinsic  normal  differences,  according 
to  the  quantity  of  blood  which  they  contain,  and  the  condition  of 
the  muscular  walls  at  the  time  of  death.  They  are  also  affected 
by  'post-mortem  changes.  The  two  ventricles  and.  auricles  do  not, 
in  health,  present  any  marked  disparity  in  capacity.  The  right 
ventricular  and  auricular  cavities  are  somewhat  larger  than  the 
left.  This  is  probably  in  some  measure  due  to  the  greater  dis- 
tension of  the  former,  in  consequence  of  the  larger  accumulation 
of  blood  at  tlie  time  of  death ;  but,  aside  from  this  circumstance, 
observations  show  that  some  disparity  exists.  The  capacity  of  the 
auricles  is  somewhat  greater  than  that  of  the  ventricles.  In  order 
to  represent  the  average  size  of  the  cavities,  it  has  been  tlie  custom 
to  say  that  each  will  contain  a  hen  s  Q^g  of  medium  size.  This 
homely  illustration  is  sufficiently  exact.  The  right  ventricle  is 
estimated  to  contain  about  two  ounces  of  liquid,  and  the  left  ven- 
tricle not  much  over  an  ounce  and  a  half.  Dilatation,  when  it 
exists  to  an  extent  to  constitute  a  lesion  of  much  importance,  and 
as  it  is  met  with  in  autopsies  of  subjects  dead  with  cardiac  disease, 
is  usually  sufficiently  well  marked  to  be  recognized  and  its  degree 
determined  by  the  eye. 

The  average  weight  of  the  heart,  as  determined  by  weighing  a 
large  number  presumed  to  be  free  from  disease,  and  taking  the 
mean,  is  not  easil}'  fixed  with  precision,  because  the  results  in 
different  hands  difier  considerably,  a  fact  which  goes  to  show  that 
the  variations  within  the  limits  of  health  are  considerable.  For 
the  reasons,  however,  which  were  stated  with  respect  to  the  average 
size  of  the  organ,  mathematical  exactness  in  giving  the  average 
weight  is  not  practically  important.  The  range  of  normal  varia- 
tion is  more  important  to  be  considered.  Bouillaud,  from  the 
results  of  Nteighing  the  hearts  in  thirteen  subjects,  fixed  the  average 


ENLARGEMENT    BY    HYPERTROPHY.  23 

weiglit,  between  the  twenty-fifth  and  sixtieth  years,  at  from  eight 
to  nine  ounces.  Dr.  Clendinning  weighed  a  much  larger  number, 
nearly  four  hundred,  all  from  subjects  over  puberty,  and  the  mean 
was  about  nine  ounces.'  Dr.  John  Eeid  found  the  average  of 
eighty-nine  male  hearts  to  be  a  little  over  11  ounces,  and  of  fifty- 
three  female  hearts  a  little  over  nine  ounces.^  It  is  sufficient  to  say 
that  the  average  weight  is  between  eight  and  ten  ounces.  And  it 
is  to  be  borne  in  mind  that  if  it  be  found  to  exceed  this  average, 
or  fall  below  it  by  one  and  two  ounces,  it  is  by  no  means  to  be 
inferred  that  the  condition  is  abnormal.  The  medium  weight  in 
the  female  is  somewhat  less  than  in  the  male.  The  weight,  as 
well  as  the  dimensions  of  the  heart,  also  increases  progressively  up 
to  an  advanced  period  of  life. 


ENLARGEMENT   BY    HYPERTROPHY. 


Under  this  title  are  included  not  only  the  rare  instances  in  which 
the  enlargement  is  due  exclusively  to  increased  thickness  of  the 
muscular  walls,  but  all  cases  in  which  the  hypertrophy,  although, 
associated  with  more  or  less  dilatation,  preponderates  over  the 
latter.  In  examining  the  heart,  after  laying  open  the  cavities  and 
removing  their  contents,  the  predominance  of  either  hypertrophy 
or  dilatation  is  generally  obvious  to  the  eye.  The  two  forms  of 
enlargement  are  combined,  in  different  cases,  in  every  degree  of 
relative  proportion.  The  question  is,  which  contributes  most  to 
the  morbid  size,  increase  of  the  structure,  or  of  the  capacity  of  the 
cavities.  Instances,  however,  occur  in  which  these  two  elements 
of  enlargement  are  about  evenly  balanced.  On  measuring  and 
weighing  the  organ,  the  excess  of  weight  is  greater  than  the  abnor- 
mal dimensions  in  proportion  as  the  hypertrophy  preponderates. 
The  walls  are  more  solid  and  resisting;  the  rounded  form  of  the 
ventricles  is  retained  when  the  organ  is  placed  on  its  posterior 
surface,  not  being  flattened  by  the  collapse  of  the  ventricular  walls. 
If  the  increased  thickness  of  the  walls  of  the  ventricles  be  due  to 
true  hypertrophy,  they  present  externally,  and  on  section,  the  ap- 
pearances of  healthy  muscular  structure.     The  microscope  shows 

'  Avoirdupois  weiglit  in  all  the  instances  cited. 
2  Dunglison's  Physiology. 


24  ENLAEGEMENT    OF    THE    HEART. 

the  tissue  to  be  normal.  The  deposit  of  fat  upon  the  heart,  between 
the  fibres,  with  fatty  degeneration  of  the  latter,  in  some  cases  adds 
to  the  bulk,  and  gives  rise  to  abnormal  appearances  of  the  surface 
and  muscular  substance.  This  constitutes  a  species  of  false  hyper- 
trophy, which  affects  certain  of  the  symptomatic  phenomena  refer- 
able to  the  heart's  action.  In  true  hypertrophy,  inasmuch  as  the 
size  of  the  muscular  fibrillas  is  not  increased,  it  follows  that  there 
takes  place  an  actual  hypergenesis  of  the  tissue.  The  several  por- 
tions of  the  heart  may  all  participate  in  the  enlargement,  or  it  may 
be  confined  to  one  or  more  of  the  anatomical  divisions  without 
extending  to  the  whole  organ.  In  the  great  majority  of  cases  all 
portions  are  involved,  but  they  are  rarely  affected  equally ;  the 
enlargement  is  more  marked  in  some  divisions  than  in  others. 
The  different  portions  may  not  present  the  same  form  of  enlarge- 
ment. Hypertrophy  may  predominate  in  one  part  and  dilatation 
in  another.  This  fact  renders  it  necessary  to  consider  the  divisions 
of  the  organ  separately.  Of  these  divisions  the  left  ventricle  is 
the  one  most  apt  to  be  affected  alone,  and  the  enlargement  is  often 
relatively  more  marked  here  than  in  other  portions,  when  the  whole 
organ  is  more  or  less  affected.  An  effect  of  enlargement  is  to 
alter  the  form  of  the  organ.  The  width  is  increased  more  than 
the  length.  The  heart  is  rendered  abnormally  broad  and  globular. 
The  conoidal  appearance  is  less  marked  than  in  health,  the  lower 
extremity  being  blunted,  and  the  pointed  apex,  as  it  were,  absorbed 
into  the  ventricle.  This  is  more  marked  when  the  enlargement  is 
confined  to,  or  involves  the  right  ventricle.  Certain  points  relating 
to  physical  signs  are  explained  by  the  change  which  the  apex 
undergoes.  The  degree  of  hypertrophy  varies  greatly  in  different 
cases.  The  thickness  of  the  left  ventricle  may  be  increased  to  an 
inch,  an  inch  and  a  half,  and  even  two  inches.  The  walls  of  the 
other  compartments  may,  in  like  manner,  be  doubled,  tripled,  and 
even  quadrupled.  The  vertical  and  transverse  dimensions  may  be 
five  or  six  inches,  or  more.  The  weight  may  exceed  two,  three, 
four,  and  even  five  times  the  normal  avera2:e.  The  larsrest  weiarht 
among  the  instances  that  have  come  under  my  personal  knowledge 
is  forty  ounces. 

The  pathological  process  giving  rise  to  true  hypertrophy  is 
hyper-nutrition.  With  few,  if  any,  exceptions,  this  process  is  a 
result  of  undue  exercise  of  the  muscular  power  of  the  organ. 
Pathologicall}'  considered,  it  is  difficult  to  account  for  the  produc- 
tion of  muscular  hypertrophy  of  the  heart,  except  as  a  consequence 


MODE    OF    PRODUCTION    OF    HYPERTROPHY.  25 

of  some  anterior  abnormal  condition  whicli  has  induced,  for  a  con- 
siderable period,  augmented  muscular  power.  The  principle  is  the 
same  as  in  the  familiar  examples  of  voluntary  muscles  becoming 
disproportionately  developed  when  inordinately  exercised.  Clinical 
observation  shows  that  in  the  majority  of  cases  of  hypertrophy, 
prior  abnormal  conditions  do  exist,  which  stand  in  a  causative 
relation  to  this  affection.  The  practical  bearing  of  this  view  of  the 
pathology  is  important.  In  much  the  larger  proportion  of  cases 
of  hypertrophy,  the  anterior  causative  conditions  are  obvious,  and 
are  seated  in  the  heart  itself,  or  in  the  large  vessels.  The  affection 
in  these  cases  may  be  distinguished  as  complicated  hypertrophy ; 
cases  of  uncomplicated  hypertrophy  being  those  in  which  the  causa- 
tive conditions  are  either  not  obvious  or  situated  remotely  from 
the  heart.' 

In  complicated  hypertrophy  the  antecedent  and  co-existing  car- 
diac affections  are  those  which  involve  over-repletion  of  the  cavities, 
either  in  consequence  of  obstruction  to  the  free  passage  of  the 
blood  through  the  orifices  and  vessels,  or  of  regurgitation  due  to 
valvular  insufficiency.  The  organ  being  unduly  distended  and 
stimulated  by  the  accumulation  of  blood,  its  action  becomes  unduly 
forcible;  the  causes  of  accumulation  being  permanent  and  often 
progressively  increasing,  the  increased  action  continues  and  aug- 
ments, and  hyper-nutrition  is  the  result.  The  hypertrophy  com- 
mences in  that  portion  of  the  heart  which  is  most  directly  affected 
by  the  complication,  but  the  several  portions  sustain  to  each  other, 
in  their  anatomical  structure  and  functions,  relations  so  close  and 
reciprocal,  that  causes  which  at  first  are  limited  to  one  part,  affect 
ultimately  the  whole  organ.  The  enlargement,  however,  prepon- 
derates in  the  portion  which  is  first  affected.  Directing  attention 
with  some  detail  to  the  mode  in  which  lesions  of  the  valves  or 
orifices  and  vessels  give  rise  to  enlargement,  we  shall  be  led  to 
consider  the  development  of  the  affection  in  the  different  anatomical 
divisions  of  the  heart,  respectively,  taking  them  up  in  the  order  of 
their  greater  relative  liability  to  become  hypertrophied.  Of  the 
several  portions,  the  left  ventricle,  as  already  stated,  is  oftenest 
enlarged ;  next  in  liability  to  enlargement  is  the  left  auricle ;  next, 
the  right  ventricle,  and,  last,  the  right  auricle. 

'  In  276  cases  of  enlargement  in  whicli  hypertrophy  predominated,  Dr.  T.  R. 
Chambers  (Decennium  Pathologicum,  Brit,  and  For.  Med.-Chir.  Rev.,  vol.  xii., 
1853),  found  the  heart  free  from  valvular  disease  in  75,  leaving  201  cases  of  com- 
plicated hypertrophy. 


26  EXLARGEMENT    OF    THE    HEART. 

The  lesions  which  especially  lead  to  hypertrophy  of  the  left 
ventricle,  are  those  seated  at  the  aortic  orifice.  Lesions  in  this 
situation  may  involve,  as  will  be  seen  hereafter,  contraction  and 
consequently  obstruction,  or  iuadequateness  of  the  valves  and  re- 
gurgitation of  blood  from  the  aorta  into  the  ventricular  cavity. 
Contraction  and  valvular  insufficiency  are  not  infrequently  com- 
bined, causing,  at  the  same  time,  obstruction  and  regurgitation. 
Either  of  these  immediate  effects  of  aortic  lesions  occasions  over- 
repletion  of  the  ventricle ;  hence,  undue  distension  and  stimulation, 
followed  by  undue  force  of  the  ventricular  contractions,  and,  sooner 
or  later,  hyper-nutrition,  usually  accompanied  with  more  or  less 
dilatation.  The  enlargement  due  to  the  effects  last  mentioned,  for 
a  time  is  limited  to  the  left  ventricle.  Eventually  the  other  com- 
partments become  enlarged.  The  right  ventricle  is  affected  because 
each  of  the  two  ventricles  participates  in  the  action  of  the  other. 
The  two  not  only  contract  synchronously,  but  are  in  part  composed 
of  muscular  fibres  common  to  both.  Hence,  causes  which  either 
weaken  or  increase  the  force  of  the  contractions  of  the  one,  exert, 
to  a  greater  or  less  extent,  a  similar  effect  on  the  contractions  of 
the  other.  Clinical  observation  shows  that  with  enlargement  of 
one  ventricle,  the  other  very  rarely  retains  its  normal  size.  This 
is  a  mode  by  which  the  enlargement  is  extended,  applicable  only 
to  the  ventricles.  Another  mode  is  more  effective  than  tbis.  The 
accumulation  of  blood  within  the  cavity  of  the  left  ventricle  offers 
an  obstacle  to  the  free  transmission  from  the  left  auricle.  The 
blood  in  passing  from  the  auricle  to  the  ventricle  meets  witli  an 
obstruction  in  the  already  repleted  ventricle.  Over-accumulation 
within  the  left  auricle  ensues ;  hence  occurs,  after  a  time,  enlarge- 
ment of  the  auricle.  This  enlargement  involves  generally  more 
or  less  thickening  of  the  walls,  but  dilatation  here  uniformly  pre- 
dominates over  hypertrophy.  Enlargement  by  hypertrophy,  in 
fact,  pertains  exclusively  to  the  ventricular  portions  of  the  heart. 
Persisting  repletion  of  the  left  auricle  offers  an  obstacle  to  the  free 
transmission  of  blood  from  the  lungs;  hence  arises  congestion  of 
the  pulmonary  vessels  proportionate  to  the  auricular  accumulation, 
the  latter  being  the  greater,  the  more  the  auricular  becomes  dilated. 
Congestion  of  the  pulmonary  vessels  offers  an  obstacle  to  the 
current  propelled  by  the  right  ventricle  into  the  pulmonary  artery ; 
hence,  undue  distension  and  excitement  of  the  right  ventricle, 
leading  ultimately  to  enlargement  of  this  portion  of  the  heart. 
Over-accumulation  and  enlargement  of  the  ri^ht  ventricle  offer  an 


MODE    OF    PRODUCTION    OF    HYPERTROPHY.  27 

obstacle  to  the  passage  of  the  blood  from  the  right  auricle  into  that 
Tcavity;  hence  result,  at  length,  dilatation  and  thickening  of  the 
walls  of  the  right  auricle.  Over-accumulation  in  this  auricle 
induces  congestion  of  the  systemic  and  portal  veins.  This  conges- 
tion offers  an  obstacle  to  the  free  passage  of  blood  through  the 
arteries  of  the  larger  circuit.  Finally,  this  latter  obstacle  reacts 
on  the  left  ventricle  and  adds  to  the  accumulation  in  that  compart- 
ment, where  commenced  the  several  links  in  the  chain  of  sequences 
tending  to  the  enlargement,  successively,  of  all  the  other  portions 
of  the  heart.  And  while  the  whole  organ  thus  becomes  implicated, 
the  causes  affecting  primarily  the  left  ventricle  are  more  and  more 
operative,  giving  preponderance  to  the  enlargement  of  the  latter. 
The  enlargement  of  the  left  ventricle,  and,  sequentially,  of  the  re- 
mainder of  the  organ,  will  be,  ccetens  pa7'{hus,  proportionate  to  the 
duration  and  degree  of  the  aortic  contraction  or  insufficiency,  or 
of  both  combined.  Obstruction  seated  in  the  aorta  either  near  or 
at  some  distance  from  the  heart,  such  as  is  incident  to  aortic  aneu- 
rism, leads  to  hypertrophy  of  the  left  ventricle  primarily,  and, 
subsequently,  of  the  other  portions.  The  effect  is  much  more 
marked  if  the  dilatation  of  the  artery  extend  to  the  orifice  render- 
ing the  valves  inadequate,  or  if  valvular  lesions  permitting  regur- 
gitation co-exist. 

Enlargement  commencing:  in  the  left  auricle  occurs  in  connection 
with  lesions  of  frequent  occurrence,  aifecting  the  mitral  orifice  and 
valves,  and  involving  either  contraction  or  insufficiency,  or  both 
these  immediate  effects.  In  auricular  enlargements,  however,  as 
just  stated,  dilatation  predominates  over  hypertrophy.  Mitral  ob- 
struction and  regurgitation  lead  to  accumulation  in  the  left  auricle, 
the  passage  of  the  blood  from  the  auricle  to  the  ventricle  being 
impeded  by  the  one,  and  a  reversed  current  from  the  ventricle  to 
the  auricle  being  incident  to  the  other.  Nest  follow  pulmonary 
congestion  and  enlargement  of  the  right  ventricle,  the  same  as 
when  these  results  take  place  in  cases  of  aortic  obstruction  and 
regurgitation.  So  far  as  the  ventricles  are  concerned  in  connection 
with  the  mitral  lesions  mentioned,  the  right  ventricle  is  first  en- 
larged, and  its  enlargement  often,  if  not  generally,  preponderates 
over  that  of  the  left  ventricle,  unless,  as  frequently  occurs,  aortic 
lesions  also  exist.  The  enlargement  of  the  right,  however,  leads  to 
that  of  the  left  ventricle,  partly  from  the  community  in  structure 
and  in  part  from  the  ultimate  effect  on  this  ventricle  of  obstructive 
accumulation  successively  in  the  right  auricle  and  systemic  veins. 


28  ENLARGEMENT    OF    THE    HEART. 

Contraction  and  valvular  insufficiency  at  the  pulmonary  orifice 
occasion,  primarily,  enlargement  of  the  right  ventricle,  precisely  as 
aortic  lesions  induce,  first,  enlargement  of  the  left  ventricle.  Le- 
sions at  the  pulmonary  orifice  after  birth,  however,  are  so  rarely 
met  with  that,  practically,  their  occasional  occurrence  may  almost 
be  disregarded  in  diagnosis.  In  foetal  life,  contraction  at  this 
orifice  is  not  very  infrequent.  It  is  the  point  of  departure  for 
many  of  the  congenital  malformations  of  the  heart.  In  these  in- 
stances, the  right  ventricle  is  often  found  enormously  hypertrophied. 

Lesions  at  the  tricuspid  orifice  being  extremely  infrequent, 
enlargement  of  the  right  auricle  rarely  occurs,  except  consecutively 
to  an  affection  of  the  right  ventricle.  Over-accumulation  in  this 
ventricle  involves  obstruction  and  accumulation  within  the  auricle 
with  which  it  communicates,  and  the  ulterior  consequences  already 
mentioned.  The  remote  and  incidental  eifects  of  obstruction  to  the 
circulation,  except  as  regards  the  size  of  the  heart,  will  be  con- 
sidered, in  connection  with  the  subject  of  valvular  lesions,  in 
another  chapter. 

Enlargement  of  the  heart,  uncomplicated  with  other  cardiac 
affections,  may  be  traced  in  some  instances  to  obstruction  at  a  dis- 
tance from  the  centre  of  the  circulation.  Pulmonary  obstruction, 
incident  to  emphysema  of  the  lungs,  and  occasionally  to  chronic 
pleurisy,  collapse,  and  dilated  bronchi,  leads  to  cardiac  enlargement. 
In  these  cases,  the  point  of  departure  is  the  right  ventricle,  and  the 
enlargement  of  this  portion  preponderates  over  that  of  the  other 
compartments.-'  Obstruction  in  the  systemic  vessels,  occurring  inde- 
pendently of  prior  disease  of  the  heart,  and  sufficient  in  degree  and 
persistence  to  give  rise  to  enlargement  of  the  heart,  is  not  so  easily 
determinable  as  pulmonary  obstruction.  It  has  been  conjectured 
that  in  this  way  Bright's  disease  of  the  kidneys  may  lead  to  cardiac 
disease,  these  affections  being  not  very  unfrequently  associated.  It 
is,  however,  a  question  whether,  in  such  instances,  the  affection  of 

'  Dr.  Gairdner,  of  Edinburgh,  has  suggested  that  enlargement  of  the  heart,  inci- 
dent to  emphysema  and  other  affections  of  the  lungs  attended  with  diminution  of 
their  substance,  may  be  produced  by  the  dilatation  of  the  chest  in  inspiration,  and 
that  obstruction  of  the  pulmonary  vessels  plays  a  subordinate  part  in  the  enlarge- 
ment. The  suction  force  thus  exerted  of  course  cannot  be  made  to  explain  hyper- 
trophy, but  only  dilatation,  nor  can  it  be  considered  as  acting  on  the  right  ventricle 
to  the  exclusion  of  other  portions  of  the  heart.  Vide  art.  in  Brit,  and  For.  MecL- 
Chir.  Rev.,  July,  1853,  entitled  "Considerations  on  the  causes  of  dilatation  of  the 
heart,  with  an  analysis  of  evidence  bearing  on  the  connection  of  that  affection  with 
disease  of  the  lung." 


MODE    OF    PEODUCTION    OF    HYPERTROPHY,  29 

the  kidneys  bo  not  consecutive  to,  and  dependent  upon,  the  affec- 
tion of  the  heart.  The  changes  which  the  arteries  undergo  in  the 
latter  part  of  life,  by  which  their  elasticity  is  impaired  and  their 
calibre  diminished,  are,  with  much  reason,  supposed  to  stand  in 
a  causative  relation  to  enlargement  of  the  heart  in  some  cases. 
These  changes,  perhaps,  in  a  measure  at  least,  account  for  the 
progressively  increasing  size  of  the  heart,  which,  according  to  the 
researches  of  Bizot,  marks  the  progress  from  middle  life  to  old  age. 

Cases  of  uncomplicated  enlargement,  as  already  stated,  are  few 
in  comparison  with  the  number  of  those  in  which  the  enlargement 
is  associated  with  other  and  anterior  cardiac  lesions.  If  from  the 
number  of  the  former  are  excluded  those  referable  to  obstruction 
situated  remotely  from  the  heart,  the  residue  is  exceedingly  small. 
Pushing  still  farther  this  elimination,  and  rejecting  the  cases  in 
which  hypertrophy  is  associated  with  dilatation,  in  other  words, 
accepting  only  cases  of  simple  hypertrophy,  their  occurrence  is  so 
rare  that  they  may  be  classed  among  the  curiosities  of  medical 
experience.  The  best  specimen  of  simple,  uncomplicated  hyper- 
trophy Avhich  has  come  under  my  observation,  was  obtained  at  the 
autopsy  of  a  young  unmarried  female,  who  died  after  an  aboftion 
had  been  procured,  in  the  latter  part  of  pregnancy,  by  a  practitioner 
of  homoeopath}^,  who  was  convicted  of  the  crime  and  sent  to  the 
State  prison.  This  female  had  apparently  been  well  and  vigorous 
until  her  pregnancy,  when  she  became  anasarcous.  The  kidneys 
presented  evidence  of  granular  degeneration.  Death  occurred  just 
after  delivery,  during  a  convulsion.  The  heart  in  this  case  weighed 
fourteen  and  a  half  ounces  ;  the  thickness  of  the  left  ventricle  was 
nearly  an  inch,  and  that  of  the  right  ventricle  a  fourth  of  an  inch. 
jSTone  of  the  cavities  appeared  to  be  enlarged.  Nothing  was 
developed  in  the  judicial  investigation  of  the  case  to  show  that 
there  had  existed  symptoms  referable  directly  to  the  cardiac  hyper- 
trophy. 

It  was  formerly  supposed  that  prolonged  functional  disorder  of 
the  heart  frequently  eventuated  in  the  development  of  hypertrophy. 
This  opinion,  sanctioned  by  Corvisart,  is  not  sustained  by  clinical 
experience.  It  may  be  fairly  doubted  if  the  palpitation  incident  to 
anemia  and  other  inorganic  causes  be  ever  competent,  in  itself,  to 
induce  hypertrophy.  At  first  view,  this  statement  may  appear 
inconsistent  with  the  fact  that  the  abnormal  growth  of  the  muscular 
walls  of  the  heart  is  the  consequence  of  abnormal  muscular  action 
of  the  organ.     This  inconsistency  disappears  when  it  is  considered 


30  ENLARGEMENT    OF    THE    HEART. 

that  functional  palpitation,  even  when  intense,  does  not  involve 
that  increase  of  power  or  strength  of  muscular  action  which  is 
incident  to  the  over-accumulation  of  blood  from  an  impediment  to 
the  circulation.  Moreover,  the  increased  action  from  nervous  ex- 
citation is  never  so  constant  and  persisting  as  that  due  to  valvular 
or  other  lesions  which  occasion  obstruction.  In  the  latter  case, 
hypertrophy  is  the  result  of  increased  action,  beginning  imper- 
ceptibly and  progressively  increasing  for  many  months,  and  even 
years. 

In  leaving  this  branch  of  the  subject,  it  should  be  stated  that, 
although  in  the  immense  majority  of  cases  enlargement  is  referable 
to  obvious  lesions  either  within  or  without  the  heart,  involving 
impediment  to  the  circulation,  a  few  instances  are  on  record  in 
•which  the  organ  attained  to  an  enormous  size,  and  no  other  lesions 
were  discoverable.  A  case  is  cited  by  Jones  and  Sieveking  in 
which  the  heart  weighed  five  pounds,  the  valves  being  perfectly 
healthy,  and  no  morbid  appearances  elsewhere  discovered  to  ac- 
count for  the  enlargement.  Perhaps  the  most  rational  explanation 
whicb  can  be  given  of  these  cases  is  that,  congenitally,  the  size  of 
the  heart  is  disproportionate  to  the  capacity  of  the  vascular  system. 
This  explanation  was  given  by  Laenuec,  and  is  adopted  by  Eo- 
kitansky. 

The  account  which  has  been  given  of  the  manner  in  which  the 
several  compartments  of  the  heart  become  enlarged  is  applicable,  in 
a  measure,  to  both  forms  of  enlargement,  viz.,  hypertrophy  and  dila- 
tation. In  the  vast  majority  of  the  cases  of  enlargement  by  hyper- 
trophy, it  is  to  be  borne  in  mind  that  the  hypertrophy  is  accom- 
panied by  more  or  less  dilatation.  The  causes  which  determine  a 
predominance  of  dilatation  will  be  more  appropriately  considered 
in  a  subsequent  section  of  this  chapter,  devoted  to  the  subject  of 
"  enlargement  by  dilatation."  The  same  causes  determine  the 
degree  of  dilatation  which  accompanies  hypertrophy  when  the 
latter  predominates.  In  cases  of  enlargement  by  hypertrophy,  the 
accompanying  dilatation,  according  to  the  views  of  some  writers, 
precedes  the  hypertrophy.  It  is  more  reasonable  to  suppose  the 
reverse  of  this,  i.  e.,  that  the  dilatation  is  consecutive  to  the  hyper- 
trophy. The  first  eflect  of  over-distension  and  stimulation  from 
an  undue  accumulation  of  blood  is  the  increased  growth  of  the 
muscular  walls.  In  the  healthy,  vigorous  action  of  the  heart,  the 
ventricles,  probably  in  general,  contract,  so  that  the  endocardial 
surfaces  come  into  apposition,  and  the  contents  of  the  cavities  are 


CONCENTRIC  HYPERTROPHY.  31 

completely  expelled.^  Over-repletion  of  the  cavities  excites  a  more 
forcible  ventricular  action,  which  for  a  time  overcomes  the  obstruc- 
tion inducing  the  repletion.  Meanwhile,  hjper-natrition  follows, 
and  hypertrophy  is  produced.  The  increased  muscular  growth  for 
a  certain  period  protects  against  the  occurrence  of  dilatation.  At 
length,  the  hypertrophy  reaches  a  limit  when  it  increases  slowly, 
if  at  all.  The  causes,  however,  persist,  and  perhaps  become  more 
and  more  operative.  Dilatation  then  ensues,  and  from  this  period 
the  progressive  enlargement  is  due  chiefly  to  augmentation  of  the 
cavities.  This  view  is  not  only  rational,  but  sustained  by  facts 
derived  from  clinical  experience.  Observation  shows  that,  as  a 
rule,  in  proportion  to  the  duration  of  organic  affections  of  the  heart 
inducing  enlargement,  dilatation  exceeds,  relatively,  hypertrophy; 
and,  in  the  great  majority  of  the  cases  in  which  death  occurs,  not 
from  affections  incidental  to  heart  disease,  but  as  a  termination  of 
the  latter,  dilatation  predominates  over  hypertrophy.  According 
to  this  view,  hypertrophy  becomes  an  important  conservative 
provision,  first,  against  over-accumulation  of  blood,  and,  second, 
against  the  more  serious  form  of  enlargement,  viz.,  dilatation. 

Hypertrophy  with  diminution  of  the  size  of  the  cavities  claims 
a  few  words.  Under  the  title  of  "  concentric  hypertrophy"^  (first 
described  and  so  named  by  Bertin),  this  was  regarded  formerly  as 
a  morbid  condition  occurring  not  very  unfrequently.  The  investi- 
gations of  Cruveilhier  and  others  within  the  past  few  years  have 
led  some  pathologists  to  reject  it  entirely  as  a  morbid  condition, 
and,  it  is  generally  conceded  that,  if  it  ever  occurs,  the  instances 
are  extremely  rare.  The  ventricular  cavities,  in  connection  with 
increased  thickness  of  the  walls,  are  sometimes  observed  after  death 
to  be  considerably  diminished.  This  fact  is  not  doubted ;  but  it  is 
supposed  that  both  the  diminished  cavities  and  the  thickened  walls 
in  such  cases  are  due  to  an  unusual  desrree  of  tonic  contraction  of 
the  muscular  fibres  persisting  after  death.  Cruveilhier  found  this 
appearance  in  the  bodies  of  persons  who  had  suffered  death  by 

'  That  the  inner  surfaces  of  the  ventricles  come  into  contact,  and  with  conside- 
rable force,  was  shown  by  an  appearance  presented  in  a  heart  contained  in  my 
collection.  A  rough,  projecting,  calcareous  deposit  existed  on  the  anterior  curtain 
of  the  mitral  valve.  Directly  opposite,  on  the  septum,  over  a  space  corresponding 
in  size,  as  well  as  situation,  to  this  deposit,  the  endocardium  had  become  thickened 
and  opaque,  evidently  due  to  the  forcible  pressure  of  the  rough,  calcareous  mass. 
The  ventricle  was  hypertrophied  and  dilated. 

^  Also  called  centripetal  hypertrophy.   (Bouillaiid.) 


32  EXLARGEMENT    OF    THE    HEART. 

decapitation.  It  has  been  observed  in  other  cases  after  death  from 
hemorrhage,  and  from  diseases  accompanied  with  much  loss  of 
fluids.  In  some  instances,  the  contracted  size  of  the  cavities  may 
be  made  to  disappear  bj  mechanical  dilatation  with  the  fingers, 
and  it  may  disappear  spontaneously  some  time  after  death,  espe- 
cially if  the  heart  be  macerated  in  water.  The  coexistence  of 
contracted  cavities  and  morbid  thickness  of  the  walls,  is  deemed 
inconsistent  with  the  conditions  giving  rise  to  hypertrophy,  and 
the  mechanism  of  its  production.  The  tendency  of  these  conditions, 
in  most  cases,  is,  undoubtedly,  to  dilatation.  Yet  it  is  conceivable 
that  causes  which  have  induced  hypertrophy  without  dilatation 
may  cease,  and  that  afterwards  the  tendency  of  the  hypertrophy  is 
to  lessen  the  ventricular  cavities.  This  is  the  more  intelligible 
when  it  is  considered  that,  according  to  the  view  which  has  been 
presented  in  the  development  of  hypertrophy  and  dilatation,  the 
former  in  point  of  time  takes  precedence.  Hypertrophy  of  the  left 
ventricle,  with  contraction  of  the  cavity,  may  be  accounted  for  in 
cases  in  which  there  exists  either  mitral  contraction  or  regurgita- 
tion. This  ventricle,  under  these  circumstances,  may  become 
hypertrophied  in  the  manner  already  considered,  while,  owing  to 
contraction  at  the  mitral  orifice,  or  regurgitation,  the  accumulation 
within  its  cavity,  instead  of  being  sufiicient  to  occasion  distension, 
for  a  time,  at  least,  is  less  than  normal,  and,  therefore,  the  tendency 
of  the  hypertroph}'-,  while  this  state  of  things  continues,  may  be  to 
contraction  rather  than  dilatation.^  Without  discussing  the  subject, 
which  does  not  possess  much  practical  importance,  the  possibility 
of  concentric  hypertrophy  must  be  admitted,  while  it  is  probable 
that,  in  the  majority  of  the  cases  formerly  so  considered,  the  appear- 
ances after  death  do  not  fairly  represent  either  the  capacity  of  the 
cavities  or  the  thickness  of  the  walls  during  life.  It  is  to  be  borne 
in  mind  that,  in  the  cases  in  which  unusual  tonic  contraction  of 
the  ventricles  is  suspected,  the  thickness  of  the  walls  may  not  be 
adequate  evidence  of  the  existence  of  hypertrophy.  The  weight  of 
the  heart  is  the  test  in  such  cases.  If  the  weight  exceed  the  limits 
of  health,  without  reference  to  the  size  of  the  cavities  or  thickness 
of  the  walls,  it  is  to  be  concluded  that  hypertrophy  exists. 

'  This  view  is  adrocated  by  Professor  M.  Forget,  of  Strasbourg,  Precis  TJi^orique 
et  Pratique  des  Maladies  du  Caur,  etc.,  1851,  p.  247.  Prof.  F.  contends  that  ab- 
normal diminution  is  liable  to  occur  whenever  an  obstruction  exists,  as  regards  the 
circulation,  at  a  point  behind  (en  arrihre)  the  diminished  cavity,  the  tendency  to 
dilatation  always  existing  if  the  obstruction  be  situated  anteriorly  (era  avanf). 


SYMPTOMS    OF    HYPERTEOPHY.  33 


Symptoms  and  Pathological  Effects  of  Hypertrophy. 

The  symptoms  of  bypertropTiy,  in  the  eases  which  come  uncler 
the  cognizance  of  the  physician,  are  generally  intermingled  with, 
and  obscured  by,  those  of  the  concomitant  cardiac  or  other  afiec- 
tions  which  have  given  rise  to  enlargement.  Cases  of  simple, 
uncomplicated  hypertrophy  are  so  rare  that  its  clinical  history  can 
hardly  be  said  to  have  been  established  by  observation.  The 
symptomatic  phenomena  which  are  described  as  distinctive  of  it 
have  been  determined  inferentially  rather  than  by  facts  observed 
in  well-authenticated  cases.  Rationally  considered,  it  is  clear  that 
the  symptoms  would  be  those  indicative  of  abnormal  energy  or 
power  of  the  heart.  Undue  determination  of  blood  to  the  head 
might  be  expected  to  occasion  certain  phenomena,  such  as  cepha- 
lalgia, flushing  of  the  face,  throbbing,  vertigo,  etc.  These  symptoms 
have  relation  to  hypertrophy  affecting  the  left  ventricle.  Assum- 
ing the  absence  of  aortic  obstruction  and  of  mitral  regurgitation, 
the  pulse  would  represent  the  power  of  the  ventricular  contractions 
by  its  force,  fulness,  and  incompressibility.  Dyspnoea,  when,  from 
any  cause,  the  action  of  the  heart  is  increased,  as,  for  example, 
after  exercise,  would  denote  that  the  hypertrophy  affected  the  right 
ventricle.  Of  the  powerful  action  of  the  heart  the  patient  would 
be  conscious  when  his  attention  was  directed  to  it,  and  it  would  be 
apparent  from  the  movements  of  parts  of  the  body  and  the  dress. 
The  digestive  and  assimilative  functions  would  not  be  expected  to 
offer  any  marked  symptoms  of  disorder.  The  muscular  strength 
would  not  be  diminished,  nutrition  would  not  be  impaired,  nor  the 
functions  of  secretion  and  excretion  interrupted.  This  is  a  brief 
account  of  a  hypothetical  case  of  simple,  uncomplicated  hyper- 
trophy, I  am  unable  to  give  a  description  based  on  personal 
observation,  or  on  an  analysis  of  reported  cases.  The  group  of 
symptoms  is  not  highly  distinctive ;  the  affection  would  be  likely 
to  be  overlooked,  and,  if  the  hypertrophy  were  but  moderate  in 
degree,  the  immediate  inconveniences  would  probably  not  be  suffi- 
cient to  lead  the  patient  to  seek  for  medical  advice. 

Associated  with  valvular  lesions,  emphysema,  aneurism,  and  other 
antecedent  and  causative  affections,  the  symptoms  distinctly  refer- 
able to  hypertrophy  are  few.  The  cerebral  symptoms  are  attribut- 
able to  obstructed  circulation  rather  than  to  an  abnormal  power  of 
the   heart.      The    same   remark    applies    to    dyspncea   and    other 


84  ENLARGEMENT    OF    THE    HEART. 

pulmonary  symptoms.  Valvular  obstruction  and  regurgitatiou 
modify,  in  a  marked  degree,  the  characters  of  the  pulse.  In  short, 
that  which  chiefly  possesses  significance  is  the  evidence  afforded  by 
observation  and  the  consciousness  of  the  patient  that  the  heart 
habitually  acts  with  undue  strength.  To  this  the  mind  of  the 
patient  becomes  accustomed,  and  he  often  appears  unconscious  of 
it,  even  when  it  is  very  marked  on  a  physical  examination  of  the 
prsecordia.  This  evidence  of  hypertrophy  lessens  in  proportion  as 
it  is  accompanied  by  dilatation,  and  finally  disappears  when  the 
latter  predominates. 

The  pathological  effects  of  hypertrophy  are  to  be  disconnected 
from  those  of  concomitant  affections  and  accompanying  dilatation. 
Thus  isolated,  it  is  not  easy  to  impute  to  it  any  special  or  very 
important  pathological  effects.  It  has  been  supposed  that  hyper- 
trophy of  the  left  ventricle  sometimes  leads  to  apoplexy  and  hemi- 
plegia, due  to  extravasation  of  blood  or  congestion,  in  consequence 
of  the  force  with  v.'hich  the  current  of  blood  is  propelled  into  the 
vessels  of  the  brain.  That  these  cerebral  affections  occur  as  effects 
of  disease  of  the  heart  is  not  to  be  denied,  but  the  cardiac  affections 
which  more  especially  tend  to  produce  them,  are  those  involving 
obstruction  to  the  return  of  blood  from  the  head.  Moreover,  it  is 
to  be  borne  in  mind  that  great  hypertrophy  of  the  left  ventricle  is 
(generally  complicated  either  with  aortic  obstruction  or  regurgita- 
tion, or  both,  and  that,  under  these  circumstances,  the  strain  upon 
the  coats  of  the  cerebral  arteries  is  not  commensurate  with  the 
force  of  the  ventricular  contractions.  Statistical  researches  show 
that  the  occurrence  of  apoplexy  in  connection  with  heart  disease, 
is  not  proportionate  to  the  degree  of  hypertrophy,^  Hypertrophy 
of  the  right  ventricle  has  also  been  supposed  to  give  rise  to 
htemoptysis  and  pulmonary  apoplexy.  But  clinical  observation 
shows  that  these  effects  very  rarely,  if  ever,  take  place,  except 
when  (as  is  often  the  case)  with  hypertrophy  of  the  right  ven- 
tricle, is  conjoined  contraction  of  the  mitral  orifice.  The  latter 
involves  an  impediment  to  the  pulmonary  circulation  more  likely 
to  o'ive  rise  to  hemorrhage  than  the  force  with  which  the  blood  is 
propelled  by  the  hypertrophied  ventricle.  Dropsical  effusion  into 
the  areolar  tissue  and  serous  cavities  (general  dropsy)  is  a  common 
effect  of  organic  disease  of  the  heart.     It  is  not,  however,  an  efiect 

'  See  Walslie  on  Diseases  of  the  Luugs  and  Heart,  second  edition,  for  an  analysis 
of  cases  collected  from  different  authors,  the  results  appearing  to  show  that  hyper- 
trophy has  little  or  no  effect  iu  determining  the  occurrence  of  apoplexy. 


PHYSICAL    SIGNS.  35 

attributable  to  l\ypertrophy.  Simple,  uncomplicated  hypertrophy 
would  be  incapable  of  producing  it.  When  it  occurs  in  connection 
with  cardiac  enlargement,  it  is  due  to  obstruction  from  valvular 
disease  or  from  dilatation. 


Physical  Signs  and  Diagnosis  of  Enlargement  and  Hypertrophy. 

The  physical  sigas  of  enlargement  of  the  heart  are  common  to 
both  forms,  viz.,  hypertrophy  and  dilatation.  After  having  con- 
sidered these  signs  in  the  present  connection,  it  will  only  be  neces- 
sary to  refer  to  them  briefly  in  treating  of  dilatation.  Incidental  to 
their  consideration  will  be  noticed  the  points  distinctive  of  enlarge- 
ment b}'  hypertrophy.  The  different  methods  of  physical  explora- 
tion contribute  evidence  of  cardiac  enlargement.  Enumerating 
them  in  the  order  of  their  relative  importance,  the  methods  avail- 
able in  the  diagnosis  are  percussion,  palpation,  auscultation,  inspec- 
tion and  mensuration.  The  signs  obtained  by  these  different  methods 
may  be  conveniently  classified  and  considered  as  follows:  1.  Ex- 
tended and  increased  dulness  in  the  pr^cordia,  as  determined  by 
percussion.  2.  Altered  situation  and  extent  of  the  apex-beat ;  im- 
pulses elsewhere  than  over  the  apex  of  the  heart;  and  abnormal  force 
of  impulse,  as  determined  by  palpation.  3.  Abnormal  modifications 
of  the  heart-sounds ;  diminished  extent  and  degree  of  the  respira- 
tory murmur  and  vocal  resonance  within  the  prtecordia,  as  deter- 
mined by  auscultation.  4.  Enlargement  of  the  prsecordia  and 
abnormal  movements,  as  determined  by  inspection.  5.  Increased 
size  of  the  chest,  as  determined  by  mensuration. 

1 .    Extended  and  increased  didness  in  the  prcecordia  as   determined  by 

2)ercussion. 

It  is  obvious  that  the  diagnostician  must  be  acquainted  with  the 
extent  and  degree  of  the  prtecordial  dulness  due  to  the  presence  of 
the  heart  in  health,  before  he  is  prepared  to  appreciate  the  signs  of 
disease  furnished  by  percussion.  With  reference  to  the  results  of 
percussion  in  health,  the  position  of  the  heart  and  its  anatomical 
relations  to  the  lungs  and  the  thoracic  walls  are  to  be  considered.^ 

The  heart  is  situated  between  the  cartilages  of  the  third  and 
sixth  ribs.     The  upper  extremity,  or  base,  is  defined  with  sufficient 

'  Vide  Fig.  1,  Frontispiece. 


86  ENLARGEMENT    OF    THE    HEART. 

precision  bj  the  upper  margin  of  the  third  rib.  The  point  or  apex 
generally  extends  to  the  fifth  intercostal  space,  near  the  junction  of 
the  rib  to  its  cartilage.  The  organ  is  situated  obliquely  within  the 
chest;  a  line  passing  through  the  longitudinal  axis  would  intersect 
obliquely  the  clavicle  near  its  acromial  extremity.  The  median 
line  and  a  vertical  line  passing  through  the  nipple,  are  convenient 
landmarks  for  indicating  the  space  which  the  heart  occupies  trans- 
versely. The  median  line  divides  the  heart,  leaving  about  one- 
third  on  the  right  and  two-thirds  on  the  left  side.  The  left  margin 
in  the  male  extends  to  a  point  just  within  the  nipple  which  is 
situated  on  the  fourth  rib  near  the  junction  of  the  rib  with  its  car- 
tilage. The  point  or  apex  is  about  three  inches  to  the  left  of  the 
median  line,  and  an  inch  within  a  vertical  line  passing  through  the 
nipple.  The  right  margin  of  the  organ  extends  from  half  an  inch 
to  an  inch  beyond  the  sternum  on  the  right  side.  Viewing  the 
several  portions  of  the  heart  in  relation  to  the  median  line,  on  the 
rioht  side  are  situated  the  rio;ht  auricle  and  about  a  third  of  the 
right  ventricle;  on  the  left  of  this  line  are  situated  two-thirds  of 
the  right  ventricle  and  the  left  auricle. 

The  relations  of  the  heart  to  the  adjacent  organs  are  important 
with  reference  to  the  signs  furnished  by  percussion  and  other  me- 
thods of  exploration.  At  the  base  are  the  large  arteries  connected 
with  the  ventricles,  viz.,  the  aorta  and  pulmonary  artery,  which 
extend  upward  beneath  the  sternum,  the  latter  to  the  level  of  the 
upper  margin  of  the  second,  and  the  former  nearly  as  high  as  the 
first  rib.  The  course  of  these  vessels,  and  their  respective  posi- 
tions relatively  to  each  other,  and  to  the  thoracic  walls,  are  of  im- 
portance in  regard  to  certain  auscultatory  signs,  and  will  be  referred 
to  in  that  connection.  The  portion  of  the  heart  situated  on  the 
right  of  the  median  line  is  covered  by  the  right  lung.^  The  lower 
border  of  the  organ,  to  the  left  of  the  median  line,  lies  on  the 
diaphragm,  which  separates  it  from  the  left  lobe  of  the  liver,  and 
toward  the  apex  from  the  stomach.  Its  relations  to  the  stomach 
are  more  or  less  extensive,  according  to  the  degree  of  distension  of 
the  hitter  organ.  The  portion  of  the  heart  lying  to  the  left  of  the 
median  line  is  only  partially  covered  by  the  left  lung;  a  part  is  in 
contact  (the  pericardium  of  course  intervening)  with  the  thoracic 
walls.  The  space  on  the  chest  beneath  which  the  heart  is  un- 
covered of  lung,  is  called  the  sui)erjicial  cardiac  region.     The  space 

'  Vide  Fig.  2,  Frontispiece. 


ANATOMICAL    RELATIONS    OF    THE    HEART.  87 

beyond  this  region  occupied  bj  the  heart,  situated  beneath  the 
right  border  of  the  left  lung,  is  called  the  deep  cardiac.region.  These 
names  will  often  recur,  and  their  import  should  be  understood. 
The  left  lung  extends  downward  on  the  median  line  to  the  level  of 
the  junction  of  the  fourth  costal  cartihige  with  the  sternum.  From 
this  point  the  border  of  the  lung  diverges,  leaving  an  irregular 
quadrangular  portion  of  the. heart's  surface  exposed.  This  space 
may  be  embraced  with  sufficient  precision  for  practical  purposes 
within  a  right  angled  triangle,  delineated  as  follows:^  The  oblique 
line,  or  hypothenuse,  is  drawn  by  connecting  a  point  at  the  centre 
of  the  sternum  on  a  level  with  the  junction  of  the  fourth  costal 
cartilage,  with  the  point  wdiere  the  apex  of  the  heart  comes  in  con- 
tact with  the  thoracic  walls,  usually  in  the  fifth  intercostal  space, 
about  an  inch  within  a  vertical  line  passing  through  the  nipple,  or 
about  three  inches  to  the  left  of  the  median  line.  The  median  line 
extending  from  the  same  point  on  the  sternum,  and  a  line  extend- 
ing transversely  from  the  point  of  apex-beat  to  meet  the  median 
line,  will  form  the  two  other  sides  of  the  triangle.  The  superficial 
cardiac  region  is  thus  bounded  on  two  of  its  sides  by  lung,  and  on 
the  greater  part  of  one  side,  viz.,  the  lower,  by  the  liver  and  sto- 
mach, with  the  diaphragm  intervening.  The  limits  to  which  the 
deep  cardiac  region  extends  beyond  those  of  the  superficial  cardiac 
region,  have  been  already  defined  in  giving  the  boundaries  of  the 
space  which  the  heart  occupies  within  the  chest. 

This  account  of  the  situation  and  anatomical  relations  of  the 
heart,  based  on  examinations  of  the  dead  subject,  is  sufficiently 
exact  for  practical  purposes ;  but  in  the  living  body,  it  is  to-  be 
borne  in  mind,  the  position  of  the  organ  relatively  to  the  thoracic 
parietes  and  the  adjacent  organs  varies  within  certain  limitations, 
not  only  in  different  persons,  but  in  the  same  person  at  different 
times.  The  size  of  the  organ  is  variable,  owing  to  a  greater  or 
less  accumulation  of  blood  in  its  cavities,  more  especially  in  the 
auricles.  The  whole  organ  is  movable  to  some  extent.  The  base 
is  comparatively  fixed,  but  the  apex  moves  freely  in  a  lateral 
direction,  and  varies  its  position  in  different  postures  of  the  body. 
The  superficial  cardiac  region  is  larger  or  smaller  according  to 
differences  in  different  persons  as  regards  the  volume  of  the  left 
lung  and  the  conformation  of  the  chest.  It  is  small  in  robust 
persons  with  deep  chests,  and  larger  in   the  slender  and  broad- 

•  Vide  Fig.  1. 


38  EXLARGEMEXT    OF    THE    HEART, 

chested.  Its  size  is  greater  at  the  close  of  an  expiration  than  after 
an  inspiration,  and  the  difference  is,  of  course,  marked  in  proportion 
as  these  respiratory  acts  are  forced.  These  are  variations  irrespect- 
ive of  those  occasioned  by  disease.  Moreover,  in  the  dead  subject, 
the  conditions  of  the  heart  and  lungs  affecting  their  mutual  rela- 
tions are  by  no  means  uniform.  The  lungs  collapse  and  shrink 
away  from  the  heart  more  or  less,  according  to  contingencies  which 
are  independent  of  disease,  and  the  state  of  the  heart,  as  regards 
the  quantity  of  blood  remaining  in  its  cavities,  depends  on  the 
mode  of  dying  and  other  circumstances.  But  happily  these  varia- 
tions are  not  sufficient  to  i^ender  unreliable  the  signs  incident  to 
diseases  of  the  heart. 

During  life,  the  space  within  which  the  heart  in  health  is  un- 
covered of  lung  and  in  contact  with  the  chest,  in  other  words,  the 
limits  of  the  "superficial  cardiac  region,"  and  the  boundaries  of  the 
heart  beyond  these  limits,  or  the  "deep  cardiac  region,"  may  be 
determined  by  means  of  percussion.  With  sufficient  care  and  prac- 
tice, the  two  regions  just  named,  to  the  left  of  the  median  line,  may 
be  determined  on  the  chest  in  the  majority  of  persons.  Their 
limits,  in  fact,  are  often  so  distinctly  definable  that,  in  view  of  the 
changes  which  occur  in  the  heart  and  lungs  after  death,  the  dimen- 
sions obtained  by  percussion  during  life  represent  more  fairly  the 
normal  relations  of  these  organs  than  measurements  with  the  parts 
exposed  to  view  in  the  dead  subject.  The  limits  of  the  superficial 
cardiac  region  are  best  ascertained  by  light  percussion,  commencing 
at  the  centre  of  the  region.  The  upper  limit  in  seventeen  healthy 
persons  in  whom  it  was  carefully  ascertained  was  the  cartilage  of 
the  fourth  rib ;  in  some  the  upper  and  in  others  the  lower  margin 
of  the  cartilage  near  the  sternum.  The  outer  limit  on  a  transverse 
line  passing  through  the  nipple  is  at  a  point  varying  from  half  an 
inch  to  an  inch  and  a  half  within  the  nipple,  the  average  distance 
in  twenty-two  persons  being  a  small  fraction  (g^gth)  over  an  inch. 
The  apex-beat,  which  is  generally  either  seen  or  felt,  determines 
the  outer  limit  at  the  base  of  the  triangle.  The  percussion-sound 
at  this  point  is  sometimes  tympanitic  from  transmitted  gastric 
resonance,  the  quality  and  pitch  of  sound  denoting  its  source.  In 
determining  the  lower  boundary  of  the  region,  the  line  of  demarca- 
tion between  the  liver  and  the  lower  border  of  the  heart  is  to  be 
distinguished  by  the  percussion-sound.  This,  which  Dr.  Walshe 
calls  "one  of  the  most  difficult  practical  problems  in  the  art  of 
percussion,"  is  readily  done  in  most  persons.     Percussing  from  a 


SUPERFICIAL    AND    DEEP    CARDIAC    REGION'S,  39 

point  over  the  liver  towards  the  heart,  viz.,  in  the  epigastrium  in  a 
direction  upwards  and  outwards  to  the  left,  the  flat,  short,  high, 
liver-sound,  at  a  little  distance  above  the  xiphoid  cartilage,  gives 
place  to  a  sound  dull  but  not  flat,  longer  and  lower  in  pitch.  Con- 
necting now  the  several  points,  already  marked  on  the  chest  with 
ink  or  some  coloring  substance,  we  have  a  diagram  representing 
the  superficial  cardiac  region  sufficiently  exact  for  ascertaining  its 
normal  dimensions  in  the  living  subject.  The  average  transverse 
diameter,  measured  from  the  median  line  to  the  outer  limit,  a  little 
below,  the  level  of  the  nipple,  in  twenty-three  healthy  persons,  was 
a  small  fraction  over  three  inches,  the  maximum  width  being  four, 
and  the  smallest  two  and  a  half  inches.  The  average  vertical 
diameter,  measured  on  the  median  line  in  sixteen  healthy  persons, 
was  two  and  a  half  inches,  the  maximum  three,  and  the  minimum 
one  and  three-quarter  inches. 

Tn  determining  the  boundaries  of  the  heart  beyond  the  limits  of 
the  superficial  cardiac  region,  that  is,  the  extent  of  the  "deep 
cardiac  region,"  or,  in  other  words  still,  the  border  of  the  preecordia, 
forcible  percussion  is  requisite,  but  not  force  enougli  to  occasion 
pain.  In  mapping  on  the  chest  this  space,  the  course  enjoined  by 
Bouillaud  has  decided  advantages,  viz.,  commencing  at  some  dis- 
tance from  the  heart  and  percussing  towards  the  prsecordia.  The 
points  at  which  the  percussion-sound  is  modified,  i.  €.,  distinctly 
dull,  being  marked  and  connected  by  lines,  the  space  occupied  by 
the  heart  is  delineated  on  the  chest ;  and  if  the  limits  of  the  super- 
ficial cardiac  region  are  delineated  on  the  same  chest,  we  have  two 
concentric  diagrams  representing  the  two  regions.  Attention  to 
the  pitch  of  the  percussion-sound  is  of  great  assistance  in  appreciat- 
ing the  dulness  within  the  deep  cardiac  region,  a  change  in  this 
respect  being  more  readily  recognized  than  the  difference  in  the 
degree  of  resonance.  Taking  the  nipple  as  a  landmark,  in  twenty- 
five  healthy  persons  (all  males)  the  left  border  was  precisely  at  the 
nipple  in  sixteen ;  in  six  instances,  it  was  within  the  nipple,  the 
greatest  distance  being  seven-eighths  of  an  inch,  and  the  smallest 
three-eighths;  in  three  instances,  it  was  without  the  nipple,  being 
half  an  inch  beyond  in  two,  and  three-eighths  of  an  inch  in  the 
remaining  instance.'  The  prascordial  region,  as  determined  by 
percussion  on  the  living  body,  in  the  majority  of  instances,  extends 

'  It  should  be  stated  that  these,  as  well  as  the  preceding  results  of  percussion, 
were  obtained  by  percussing  -srhile  the  persons  were  in  a  sitting  posture. 


40  ENLAEGEMENT    OF    THE    HEART. 

somewhat  farther  to  the  left  of  tlie  sternum  than  when  this  region 
is  viewed  in  the  dead  subject,  a  fact  doubtless  owing  to  the 
presence  of  a  larger  quantity  of  blood  within  the  cavities  of  the  left 
side  of  the  heart  during  life.  On  the  right  side  of  the  sternum,  on 
a  level  with  the  nipple,  dulness  is  generally  appreciable  within  a 
space  varying  from  half  an  inch  to  an  inch.  The  percussion-sound 
over  the  third  rib  near  the  sternum  is  generally  sufficiently  modi- 
fied on  percussing  from  above  downwards  to  indicate  the  base  of 
the  heart  in  this  situation.* 

The  foregoing  details,  which  have  been  given  as  succinctly  as 
possible,  are  essential  as  constituting  the  basis  of  the  physical  signs 
of  enlargement  of  the  heart.  The  latter,  after  these  preliminaries, 
may  be  briefly  presented.  The  area  of  prascordial  dulness  exceeds 
the  limits  of  health  in  proportion  as  the  volume  of  the  heart  is 
abnormally  increased.  The  effect  of  an  enlarged  heart  is  especiallj^ 
manifest  in  the  superficial  cardiac  region.  The  heart,  in  proportion 
to  its  augmented  bulk,  pushes  aside  the  borders  of  the  lungs, 
leaving  a  larger  portion  of  its  anterior  surface  uncovered  and  in 
contact  Avith  the  thoracic  walls.  The  superficial  cardiac  region 
becomes,  of  course,  proportionately  larger  than  in  health.  This 
effect  is  certainly  the  rule,  and  the  exceptional  instances  described 
by  some  writers^  in  which  the  heart  buries  itself  beneath  the  lungs, 
leaving  its  anterior  surface  covered  to  the  same  extent  as  in  health, 
must  be  extreraelj^  rare,  assuming  the  volume  of  the  lungs  to  be 
nornial.  The  enlargement  of  the  superficial  cardiac  region  is  espe- 
cially marked  transversely  to  the  left  of  the  median  line,  owing  to 
the  heart  increasing  more  in  width  than  in  length.  The  apex  of 
the  organ  is  generally  removed  to  the  left  of  its  normal  situation, 

'  The  combination  of  percussion  and  auscultation,  or  auscultatory  percussion,  as 
proposed  and  practised  by  Drs.  Cammann  and  Clark,  of  New  York,  is  undoubtedly 
well  adapted  to  determine  witli  ease  and  accuracy  the  boundaries  of  the  heart. 
See  New  York  Journal  of  Medicine,  July,  1840.  That  this  mode  is  not  more  gene- 
rally employed  is  because  percussion,  as  usually  practised,  suffices  for  ordinarj^ 
practical  purposes.  The  stethoscope  recently  invented  by  Dr.  Cammann  is  well 
suited  to  auscultatory  percussion.  The  publication  by  Drs.  Cammann  and  Clark 
just  referred  to,  contains  the  average  dimensions  of  the  space  occupied  by  the  adult 
heart  in  a  series  of  examinations.     The  following  are  the  mean  results  : — 

Male.  Female. 

Vertical    diameter        .         .     4  in.    0  lines  3  in.    7  lines 

Transverse       "  .         .     4  "      4    "  4  "      1  line 

Right  oblique  "  .         .     4  "    10     "  4  "    10  lines 

Left  oblique  '  "  .         .     3  "    10    "  3  "      7    " 

2  Traite  do  Diagnostic,  par  Racie. 


SIGN'S    OBTAIXED    BY    PERCUSSION.  41 

owing  partly  to  tlie  oblique  position  of  the  heart,  and  in  part  to  the 
fixedness  of  the  base  of  the  organ,  the  latter,  with  the  diaphragm 
below,  offering  mechanical  resistance  to  much  extension  in  a  verti- 
cal direction.  The  apex  being  free,  is  moved  readily  in  a  lateral 
direction.  The  evidence,  therefore,  of  the  heart  being  abnormally 
uncovered  of  lung,  and  of  the  extent  of  its  surface  in  contact  with 
the  chest,  is  obtained  b}''  percussing  from  the  median  line  towards 
the  nipple  and  towards  the  point  where  the  apex-beat  is  felt.  The 
lateral  diameter  of  the  superficial  cardiac  region  at  the  inferior 
boundary,  i.  e.,  between  the  median  line  and  point  of  apex-beat, 
may  be  one,  two,  and  even  three  inches  greater  than  in  health. 
The  superficial  dulness  instead  of  ending  an  inch  within  a  vertical 
line  passing  through  the  nipple,  extends  to  this  line,  or  from  one 
to  two  inches  beyond  it.  The  presence  of  the  apex-beat  enables  us 
to  determine  the  diameter  in  this  situation  without  practising  per- 
cussion. This  point  may  be  more  or  less  lowered,  as  well  as 
carried  to  the  left.  It  is  frequently  found  in  the  sixth,  and  some- 
times even  in  the  seventh  intercostal  space,  the  inferior  boundary 
of  the  superficial  cardiac  region  being,  of  course,  proportionately 
lower  than  in  health.  Percussing  next  from  the  left  margin  of  the 
sternum  on  or  just  below  the  level  of  the  nipple,  the  superficial 
dulness  may  be  found  to  extend  to  the  nipple,  or  half  an  inch,  an 
inch,  or  even  farther,  beyond  it.  The  diameter  of  the  region  here 
will  correspond  to  the  abnormal  width  of  the  heart.  Other  things 
being  equal,  the  enlargement  of  the  heart  transversely  may  be 
accurately  measured  by  the  extent  to  which  the  diameter  of  the 
superficial  cardiac  region  in  this  situation  is  increased.  Bxit  it  is 
to  be  borne  in  mind  that  the  normal  situation  of  the  outer  limit  of 
this  region  is  not  the  same  in  all  persons.  The  average  distance 
within  the  nipple  is  verj'  nearly  an  inch,  but  the  variation  within 
the  range  of  health,  as  has  been  seen,  is  from  half  an  inch  to  an 
inch  and  a  half.  If  the  superficial  dulness  extend  to  Avithin  half 
an  inch  of  the  nipple,  or  possibly  even  within  a  still  shorter  dis- 
tance, it  may  not  be  due  to  abnormal  enlargement;  and,  on  the 
other  hand,  in  a  person  Avhose  heart  is  normally  covered  by  lung 
an  inch  and  a  half  within  the  nipple,  superficial  dulness  extending 
to  a  point  within  half  an  inch  of  the  nipple  would  denote  consider- 
able enlargement  of  the  heart.  If  the  area  of  superficial  dulness 
proper  to  the  individual  be  not  known,  an  abnormal  increase  of  its 
dimensions  cannot  in  any  case  be  assumed  unless  the  lateral  dia- 
meter extend  nearlj'-  or  quite  to  the  nipple.     Here,  as  in   other 


42  ENLARGEMENT    OF    THE    HEART. 

instances,  the  extreme  limits  of  healthy  variation  are  of  greater 
practical  consequence  than  averages.  In  determining,  however, 
whether  the  heart  be  enlarged  or  not,  the  distance  from  the  apex  to 
the  median  line  is  to  be  taken  into  account,  and  also  the  signs 
obtained  by  other  methods  of  exploration  than  percussion. 

The  degree  of  dulness  within  the  superficial  cardiac  region  is,  in 
general,  greater  than  in  health  in  proportion  to  the  enlargement. 
In  health,  a  portion  of  the  heart  is  imbedded  in  lung  sufficient  to 
occasion  the  transmission  of  more  or  less  pulmonary  resonance 
over  the  whole  of  the  praacordia.  The  degree  of  normal  dulness 
differs  in  different  persons.  It  is  generally  marked,  and  sometimes 
approaches  to  flatness.  It  is  sufficient  to  render  the  limits  of  the 
region  distinctly  definable,  except  when  great  obesity  exists,  or,  in 
the  female,  when  the  mammary  development  is  unusually  large. 
It  is  sufficiently  intelligible  that,  in  proportion  as  the  lung  is 
pushed  aside  in  cases  of  enlargement,  the  dulness  will  be  greater  in 
degree  than  in  health.  In  some  instances  it  amounts  to  flatness. 
It  is  equally  obvious  that  the  sense  of  resistance  felt  in  practising 
percussion  will  be  marked  according  to  the  increased  bulk  of  the 
heart. 

It  is  important  to  bear  in  mind  that  increased  extent  and  degree 
of  superficial  dulness  are  signs  of  enlargement  of  the  heart,  with 
this  provision,  viz.,  that  the  lungs  are  free  from  disease.  The  size 
of  the  area  is  affected  by  abnormal  conditions  of  the  latter  organs, 
as  well  as  the  heart.  In  phthisis,  the  left  lung  is  frequently  con- 
tracted, so  that  the  anterior  margin  is  removed  towards  the  border 
of  the  heart,  leaving  a  larger  portion  of  the  heart's  surface  in  con- 
tact with  the  thoracic  walls,  even  though  the  size  of  the  organ  may 
be  less  than  in  health.  A  similar  result  follows  chronic  pleurisy, 
the  lung  not  expanding,  and  resuming  its  normal  volume  suffi- 
ciently to  cover  the  heart  as  in  health.  Happily,  in  these  excep- 
tional cases  the  liability  to  error  is  slight,  for  the  existence  of 
tuberculosis  is  determined  without  difficulty,  and  the  retrospective 
diagnosis  of  pleurisy  is  also  easily  made.  The  pra3Cordial  space  is 
not  enlarged,  and  all  doubt  is  removed  by  defining  the  boundaries 
of  the  deep  cardiac  region. 

The  relations  of  the  heart  and  lungs  are  also  affected  by  a  variety 
of  causes,  irrespective  of  morbid  conditions  of  either  of  these  organs, 
such  as  enlargement  of  the  liver,  dilatation  of  the  stomach,  aneurism 
of  the  aorta,  enlarged  spleen,  ascites,  pregnancy,  tumors  in  the  me- 
diastinum, etc.   These  disturbing  causes  are  generally  determinable; 


SIGNS    OBTAINED    BY    PERCUSSION.  43 

and  the  importance  of  not  limiting  exploration  to  tlie  prascordia, 
but  extending  the  examination  over  the  chest  and  abdomen  in 
order  to  exclude  these  and  other  affections  which  alter  the  normal 
disposition  of  the  heart  and  lungs,  is  sufficiently  obvious.  Errors 
of  diagnosis  are  sometimes  attributable  to  neglect  of  this  precaution. 

The  limits  of  deep  dulness  are  not  extended  beyond  those  of 
superficial  dulness  proportionately  to  the  degree  of  enlargement  of 
the  heart,  but  it  is  sometimes  desirable  to  ascertain  the  actual  space 
which  the  heart  occupies.  Percussing  from  without  the  heart  to- 
ward the  prgecordia,  the  lateral  borders  of  the  organ  may  generally 
be  determined  without  great  difficulty,  and  delineated  on  the  chest. 
The  enlargement  of  the  deep  cardiac  region  is  not  only  manifested 
by  dulness  extending  more  or  less  without  the  left  nipple,  but  also 
beyond  its  normal  boundary  to  the  right  of  the  sternum.  Not  only 
the  extent  of  this  region,  but  the  form  of  the  heart  may  be  deline- 
ated, and  the  latter  is  of  diagnostic  significance  as  respects  the  dis- 
crimination between  hypertrophy  and  dilatation,  the  latter  increasing- 
more  than  the  former  the  width  in  proportion  to  the  length  of  the 
heart. 

The  evidence  afforded  by  percussion  of  enlargement  of  the  heart 
is  much  less  marked,  if,  in  conjunction,  the  left  lung  be  aflbcted 
with  emphysema.  This  combination  is  not  infrequent.  The  effect 
of  emphysema  of  the  left  lung  is  to  lessen  and  even  abolish  the 
superficial  cardiac  region.  The  anterior  border  of  the  lung  may 
be  extended  forward  so  that  the  whole  surface  of  the  heart  is 
covered.  The  heart,  too,  is  often  depressed  below  its  normal 
situation  by  the  pressure  of  the  dilated  lung.  The  co-existence  of 
emphysema,  thus,  renders  the  area  of  the  superficial  cardiac  region 
no  longer  an  index  of  the  existence  and  the  degree  of  enlargement 
of  the  heart.  The  limits  of  the  deep  cardiac  region  are  alone  to  be 
depended  on,  and  they  are  not  always,  under  these  circumstances, 
easily  defined.  The  combination  renders  the  diagnosis  difficult  by 
impairing  also  concurrent  signs  of  enlargement  obtained  by  auscul- 
tation, inspection  and  palpation.  Moreover,  the  symptoms  of  em- 
physema are  liable  to  be  confounded  with  those  which  are  due  to 
disease  of  heart.  The  individual  cases  in  which  this  difficulty  in 
diagnosis  exists  are  easily  recognized,  for  the  signs  of  emphysema 
are  sufficiently  explicit;  and  in  a  certain  proportion  of  these  cases 
the  diagnostician  must  be  content  to  rely  in  a  great  measure  on  the 
well-known  pathological  association  of  the  two  affections,  deter- 
mining the  relative  proportion  of  each  approximatively. 


44  ENLARGEMENT    OF    THE    HEART. 

Enlargement  of  the  heart  results  from  different  pathological  con- 
ditions. In  addition  to  the  two  forms,  to  the  consideration  of  which 
this  chapter  is  devoted,  viz.,  hypertrophy  and  dilatation,  the  organ 
acquires  an  abnormal  size  from  the  accumulation  of  blood  within 
its  cavities  and  the  deposit  of  morbid  products  and  fat  on  its  surface. 
The  question  may  be  here  raised,  whether  percussion  furnishes  data 
for  the  differential  diagnosis  of  the  different  varieties  of  enlarge- 
ment. Hypertrophy  or  dilatation,  as  has  been  seen,  may  be  limited 
to  portions  of  the  heart,  or  may  disproportionably  affect  certain 
portions.  It  is  stated  that  the  dulness  extends  more  to  the  left  of 
the  median  line  .when  the  left  ventricle  is  the  seat  of  enlargement, 
and  is  more  manifest  on  the  opposite  side  when  the  right  ventricle 
is  affected.  The  relations  of  the  two  ventricles,  however,  is  such 
that,  in  view  of  the  position  of  the  heart  and  the  movableness  of 
the  body  and  apex,  the  left  border  is  extended  in  proportion  as  the 
right  side  is  increased  in  size;  and  it  may  fairly  be  doubted  whether, 
as  a  rule,  the  foregoing  statement  holds  good  clinically.  The  right 
or  left  auricle,  belonging  to  the  base  which  is  comparatively  fixed, 
when  considerably  enlarged,  may  occasion  a  greater  relative  extent 
of  dulness  on  the  corresponding  side  of  the  sternum.  This  remark 
is  also  applicable  to  distension  of  the  cavities  of  the  heart  by  the 
accumulation  of  blood.  Great  distension  of  the  right  side  of  the 
heart,  which  occurs  in  some  cases  of  obstruction  to  the  pulmonary 
circulation,  may  be  manifested  by  an  abnormal  extent  of  dulness 
over  the  site  of  the  rio'ht  auricle;  and  this  extent  of  dulness  mav 

CD  J  »/ 

be  found  to  have  diminished  when  the  causes  of  obstruction  are 
removed.  The  ability  to  distinguish  between  hypertrophy  and 
dilatation  by  the  percussion-sound  is  more  than  questionable.  This 
is  a  nicety  which  the  student  should  not  attempt  to  acquire,  for  in 
proportion  as  he  might  imagine  that  he  had  made  the  acquisition, 
would  be  his  liability  to  error  in  practically  trusting  to  it.  The 
same  remark  is  applicable  to  the  endeavor  to  determine  by  percus- 
sion that  enlargement  of  the  heart  is  due  to  the  deposit  of  fat  or 
morbid  products  on  its  surface.  Very  considerable  enlargement  in 
a  transverse  direction  of  the  superficial  and  deep  cardiac  regions, 
however,  is  presumptive  evidence  that  the  increased  bulk  is  due  to 
dilatation  rather  than  hypertrophy,  for  the  former,  more  than  the 
latter,  tends  to  increase  the  width  of  the  organ  and  also  to  give  rise 
to  excessive  augmentation  of  size.  On  the  other  hand,  if  percussion 
show  that  the  heart  is  considerably  lengthened,  and  that  the  trans- 
verse enlargement  is  not  to  much  extent  disproportionate  to  the 


SIGNS    OBTAINED    BY    PALPATION.  45 

vertical,  tlie  presumption  is  in  favor  of  hypertrophy  rather  than 
dilatation. 

Enlarged  extent  and  degree  of  prascordial  dulness  are  produced 
by  liquid  accumulation  within  the  pericardial  sac,  as  well  as  by 
enlargement  of  the  heart.  Both  may  co-exist,  and  then  the  evidence 
afforded  by  percussion  of  cardiac  enlargement  ceases  to  be  available. 
The  points  of  distinction  between  the  prsecordial  dulness  due  to 
liquid  accumulation  within  the  pericardial  sac,  and  that  due  to 
enlargement  of  the  heart,  are  important,  and  will  be  considered  in 
connection  with  the  subject  of  pericarditis. 

2.  Altered  situation  and  extent  of  the  apex-heat;  impulses  elsewhere  than 
over  the  apex  of  the  heart,  and  abnormal  force  of  impulse,  as  deter- 
mined hy  palpation. 

The  point  at  which  the  apex,  or  pointed  extremity  of  the  heart, 
presses  with  an  impulsive  force  against  the  thoracic  walls,  is  in  the 
fifth  intercostal  space,  the  person  examined  being  in  the  sitting- 
posture.  Of  twenty-five  healthy  persons  examined,  none  presented 
an  exception  to  this  rule.  In  this  intercostal  space,  the  impulse  is 
felt  over  an  area  varying  from  half  an  inch  to  an  inch  and  a  half, 
in  health.  The  average  transverse  diameter  of  this  area,  in  thir- 
teen persons,  was  a  fraction  (y^th)  over  an  inch.  The  centre  of 
this  area,  where  the  force  of  the  beat  is  greatest,  is  situated  within 
a  vertical  line  passing  through  the  nipple,  at  a  distance  from  that 
line  varying  from  two  inches  to  three-eighths  of  an  inch,  the 
average,  in  eighteen  persons,  being  a  fraction  (^th)  over  an  inch. 
The  distance  from  the  median  line  to  the  centre  of  this  area  varies 
between  three  inches  and  five-eighths  and  tw^o  inches  and  five- 
eighths,  the  average,  in  fifteen  persons,  being  a  fraction  (xsth)  under 
three  inches.  Measured  from  a  transverse  line  passing  through  the 
nipple,  the  distance  varies  from  an  inch  and  an  eighth  to  two 
inches,  the  average,  in  eight  persons,  being  a  fraction  (7th)  over  one 
and  a  half  inch.  These  are  the  relations  of  the  apex-beat  in  the 
sitting  posture.  Deviations  take  place  when  the  posture  is  changed, 
owing  to  the  movableness  of  the  apex  and  body  of  tlie  heart.  In 
the  recumbent  position  on  the  back,  the  beat  is  frequently  felt  in 
the  fourth  intercostal  space,  the  same  relations  laterally  to  the 
nipple  and  median  line  as  in  the  sitting  posture  being  preserved. 
The  frequency  with  which  this  is  observed  has  led  some  late 
writers  to  state,  incorrectly,  that,  as  a  rule,  the  apex-beat  is  in  the 


46  ENLARGEMENT    OF    THE    HEART. 

fourth  intercostal  space.'  Lying  on  the  right  side,  the  centre  of  the 
area  within  which  the  beat  is  felt  is  removed  about  half  an  inch 
nearer  the  sternum.  Lj'ing  on  the  left  side,  the  beat  is  removed  to 
the  left,  so  that  the  centre  of  the  area  generally  falls  on  a  vertical 
line  passing  through  the  nipple,  and  the  impulse  is  felt  half  an  inch 
without  this  line.  The  respirator}'"  movements  sometimes  affect  the 
situation  of  the  apex-beat.  I  have  not  observed  it  to  be  lowered 
by  a  full  inspiration,  but  it  is  occasionally  raised  from  the  fifth  to 
the  fourth  intercostal  space  by  a  forced  expiration,  the  persons 
examined  in  the  sitting  posture.  The  apex-beat  is  not  unfrequently 
inappreciable  to  the  touch  in  healthy  persons,  in  the  sitting  pos- 
ture. The  persons  in  whom  it  is  wanting  have  generally  deep 
chests.  Thickness  of  the  soft  parts  also  prevents  it  from  being 
felt.  It  is  lost  in  the  recumbent  position  on  the  back  in  some 
instances  in  which  it  is  felt  when  the  person  is  sitting.  It  is  still 
oftener  lost  when  the  person  lies  on  the  right  side,  but  very  rarely 
when  the  position  is  on  the  left  side.  In  the  latter  position  it  is 
sometimes  felt  when  not  appreciable  in  any  other. 

The  force  of  the  impulse  varies  in  different  persons.  It  is  rarely 
strong  when  the  person  is  tranquil  and  free  from  mental  agitation. 
It  is  generally  quite  feeble.  It  is  almost  invariably  less  when  the 
person  lies  on  the  back  than  in  the  sitting  posture ;  and  it  is  still 
more  diminished,  when  not  lost,  if  the  position  be  on  the  right  side. 
Lying  on  the  left  side  increases  the  impulsive  force ;  the  beat  is 
strongest  in  this  position.  The  sensation  on  applying  the  fingers 
over  the  area  of  the  apex-beat,  as  remarked  by  Dr.  Walshe,  is  that 
of  a  gliding  as  well  as  an  impulsive  movement.  It  is  not  that  of  a 
percussion  or  blow.  It  is  suflQcieutlj^  clear,  on  a  little  reflection, 
that  the  apex  of  the  heart  does  not  withdraw  itself  from  the 
thoracic  walls,  and  then  come  into  forcible  contact  through  an  open 
space.  The  pressure  of  the  atmosphere  on  the  exterior  surface  is 
sufficient  to  prevent  the  heart  receding  from  the  chest,  except  so 
far  as  it  is  displaced  by  intervening  pulmonary  tissue.  The  beat 
must,  of  necessity,  be  produced  by  movements  incident  to  the 
changes  in  form  of  the  organ,  and  not  to  the  tilting  forward  of  the 
apex,  as  was  formerly  imagined. 

The  mechanism  of  the  heart's  impulse  has  been  a  fruitful  theme 
for  discussion.  It  does  not  fall  within  the  scope  of  this  work  to 
consider   the  various  theories  which  have  been  proposed.      The 

'  Vemeuil,  1852,  Racle,  op.  cit. 


MECHANISM    OF    THE    HEAET's    IMPULSE.  47 

subject,  however,  naturally  presents  itself  in  this  connection,  and 
claims  a  few  remarks.  It  is  generally  admitted  that  the  beat 
occurs  synchronousl}''  with  the  S3^stolic  contraction  of  the  ventricles. 
This  is  denied  by  some,  and  a  theory  which  attributes  it  to  the 
shock  of  the  current  of  blood  propelled  into  the  ventricles  by  the 
contraction  of  the  auricles,  numbers  among  its  supporters  several 
distinguished  names.  Without  discussing  this  theory,  the  improba- 
bility that  the  auricles  possess  sufficient  power  of  contraction  to 
account  for  the  phenomena  pertaining  to  the  impulse,  and  the  fact 
that  the  beat  and  the  pulsation  of  the  large  arteries  near  the  heart 
(e.  (/.,  the  carotids)  occur  without  any  appreciable  interval'  of  time, 
together  with  the  observations  of  vivisectors,  seem  to  render  it  con- 
clusive that  the  commonly  received  doctrine  is  correct.^  It  may 
also  be  assumed  that  the  impulse  is  produced  by  the  apex  of  the 
heart,  as,  in  fact,  is  assumed  in  the  expression  "apex-beat."  The 
question,  then,  resolves  itself  into  this:  In  what  manner  do  the 
systolic  movements  of  the  heart  cause  the  apex  to  press  with  a 
certain  degree  of  impulsive  force  against  the  thoracic  walls?  This 
question  is  in  a  great  measure  answered  if  it  be  conceded  that  the 
apex  of  the  heart  is  elongated  during  the  ventricular  systole. 
Some  of  the  older  anatomists,  Galen,  Yesalius,  Harvey,  and,  later, 
John  Hunter,  entertained  this  view ;  while  it  was  denied  by  Steno, 
Lancisci,  Haller,  and  others.  More  recently,  Dr.  Hope  and  others, 
resorting  to  vivisections  practised  on  animals  of  large  size,  were  led 
to  conclude  that  during  the  systolic  contraction  of  the  ventricles 
the  heart  is  shortened  by  an  approximation  of  the  apex  towards 
the  base.  It  is  difficult  to  understand  how  careful  observers  should 
be  deceived  in  this  regard,  but,  in  the  mind  of  the  author,  this  con- 
clusion is  undoubtedly  erroneous.  Drs.  Pennock  and  Moore,  in 
their  vivisections  in  1839,  satisfied  themselves  that  the  heart  elon- 
gates during  the  ventricular  contractions,  and  they  even  measured 
the  extent  of  elongation.  For  several  years.  Prof.  Dalton,  of  New 
York,  has  been  accustomed,  in  his  courses  of  instruction  in  Physio- 
logy, to  demonstrate  this  fact,  and  the  author  has  had  an  opportunity 
of  witnessing  a  demonstration  by  him  on  an  animal  of  considerable 

'  The  reader,  desirous  of  knowing  the  grounds  on  wlaich  the  diastolic  theory  of 
the  heart's  impulse  is  sustained,  is  referred  to  the  treatise  on  General  Pathology, 
by  Prof.  Alfred  Stille ;  and  for  a  still  more  elaborate  exposition  to  the  Traits  Ex- 
perimental et  Clinique  cV Auscultation,  par  .J.  H.  S.  Beau,  Paris,  1S56.  A  review  of 
the  latter  by  the  author  is  contained  in  the  American  Journal  of  Medical  Sciences, 
No.  for  January,  1857. 


48  ENLARGEMENT    OF    THE    HEART. 

size  (a  sheep),  while  engaged  in  writing  this  chapter.  The  sj'stolic 
elongation  of  the  heart  is  therefore  assumed  in  this  work,  in  oppo- 
sition to  the  statements  of  most,  if  not  all  previous  writers  on  the 
diseases  of  this  organ.'  In  elongating,  the  heart  performs  a  revolv- 
ing or  spiral  movement  from  left  to  right.^  It  is  thus  easy  to  per- 
ceive that  the  extremity  of  the  organ  presses  against  the  chest  with 
an  impulsive,  boring  movement^  more  or  less  forcible,  according  to 
the  power  of  the  ventricular  systole.  Admitting  the  correctness  of 
these  statements,  the  mechanism  of  the  impulse  seems  sufficiently 
explained ;  but  the  inquiry  arises,  is  the  elongation  of  the  apex  due 
directly  to  the  muscular  contraction  of  the  ventricles,  or  to  an 
intermediate  force  derived  from  the  blood  impelled  by  the  systole 
against  this  extremity  of  the  heart?  A  German  theory,  ascribed 
to  Gutbrod,  but,  according  to  Dr.  Markham,  proposed  by  Dr. 
Alderson  in  an  English  quarterly  journal  as  long  ago  as  1825, 
attributes  the  impulse  to  a  reversed  current  of  blood  within  the 
ventricles.  This  is  known  as  the  "Segner's  water  wheel,"  and  the 
"  recoil"  theory.  It  is  adopted  by  Prof.  Skoda,  and  by  the  author 
of  a  late  English  work  on  diseases  of  the  heart.  Dr.  Markham. 
The  explanation  of  the  impulse,  according  to  this  theory,  is  thus 
given  by  Dr.  Gutbrod  :^  "  It  is  a  well-known  phj^sical  law,  that 
when  a  fluid  escapes  from  a  vessel,  the  equality  of  pressure  pro- 
duced by  the  fluid  on  the  walls  of  the  vessel  is  lost,  for  there  is  no 
pressure  at  the  opening  whence  the  fluid  escapes;  but  at  that  part 
of  the  vessel  which  is  opposite  to  the  opening,  the  pressure  is  still 
exerted.  This  pressure  it  is  which  sets  Segner's  wheel  in  motion, 
produces  the  recoil  of  firearms,  etc.  By  contraction  of  the  ven- 
tricles, the  pressure  which  the  blood  exerts  upon  the  walls  of  the 
heart,  opposite  to  the  opening  whence  the  stream  escapes,  causes  a 
movement  of  the  heart  in  a  direction  contrary  to  that  of  the  stream 
of  blood,  and  by  this  movement  the  impulse  of  the  heart  against 
the  walls  of  the  thorax  is  produced.  The  heart  is  driven  in  a 
direction  contrary  to  that  of  the  arteries,  with  a  force  proportionate 

'  The  modern  revival  of  the  belief  in  the  systolic  elongation  of  the  heart,  may 
be  characterized  as  the  American  doctrine.  It  does  not  appear  to  have  been  as 
yet  adopted  on  the  other  side  of  the  Atlantic.  Vide  Dalion^s  PIvjsiology,  Phila- 
delphia, 1859. 

-  The  movement  of  the  apex  from  left  to  right  with  the  ventricular  systole,  is 
sometimes  very  ai^parent  when  the  thoracic  walls  are  much  thinned  by  emaciation. 
Vide  case  of  M.,  Private  Records,  vol.  x.  page  64S. 

^  A  Treatise  on  Auscultation  and  Percussion,  by  Dr.  Joseph  Skoda.  Translated 
l)y  Dr.  Markham. 


APEX-BEAT    IN    ENLAEGEMENT.  49 

to  tlie  quantity  and  the  velocity  of  tte  current  of  blood."  This 
theory  is  controverted  by  different  writers ;'  but  without  entering 
into  a  discussion  of  its  merits,  it  is  rendered  gratuitous  by  the  fact 
that  the  elongation  of  the  heart  occurs  when  its  cavities  are  entirely 
free  from  blood.  If  the  heart  be  quickly  removed  from  a  living 
animal,  the  auricles  opened  and  the  organ  placed  in  a  vertical  posi- 
tion with  the  base  downward,  the  contractions  of  the  ventricle 
continue  for  several  minutes,  and  the  elongation  in  this  experiment 
is  conspicuously  manifest.^  This  shows  conclusively  that  the 
elongation  takes  place  independently  of  the  current  of  blood.^ 

Directing  attention  now  to  the  signs  of  enlargement  and  of  hyper- 
trophy obtained  by  palpation,  those  relating  to  the  situation  of  the 
apex-beat  are  to  be  first  noticed.  The  apex-beat  is  carried  to  the 
left  of  its  normal  situation  and  frequently  lowered  when  the  bulk 
of  the  heart  is  increased.  These  changes  are  among  the  most 
constant  and  reliable  of  the  signs  of  enlargement.  The  beat  may 
be  felt  one,  two,  or  even  three  inches  without  the  nipple.  It  may 
be  found  in  the  sixth  and  even  in  the  seventh  intercostal  space. 
The  distance  to  which  it  is  removed  in  these  directions,  assuming 
that  the  alterations  depend  exclusively  on  the  increased  bulk  of  the 
heart,  constitutes  a  criterion  for  estimating  the  amount  of  enlarge- 
ment. It  must,  however,  be  considered  that  abnormal  conditions 
extrinsic  to  the  heart  alter  the  relations  of  the  apex  to  the  walls  of 
the  chest,  such  as  enlargement  of  the  left  lobe  of  the  liver,  disten- 
sion of  the  stomach,  ascites,  enlarged  spleen.     These  and  others 

'  Vide  uote  to  French  translation  of  Skoda's  Treatise,  by  tlie  translator,  Dr. 
Aran. 

^  For  an  illustration  of  this  experiment,  vide  Dalton's  Physiology. 

^  Prof.  H.  Bamberger,  of  Wiirzburg,  has  reported  a  case  in  which  a  healthy  man 
attempted  to  commit  suicide  by  stabbing  himself  in  the  breast  with  a  sharp  knife. 
The  wound  was  at  the  lower  margin  of  the  fifth  rib,  within  the  nipple,  and  the  man 
had  evidently  selected  the  spot  where  the  heart's  impulse  was  felt.  On  pressing 
his  finger  into  the  wound,  Prof.  B.  felt  the  apex  of  the  heart  distinctly,  the  peri- 
cardium evidently  having  been  opened.  He  availed  himself  of  the  opportunity 
to  study  the  movements  of  the  heart,  and  he  states  as  follows :  "  When  my  finger 
was  introduced  from  the  point  toward  the  back,  I  could  convince  myself  with  the 
greatest  certainty  that  at  every  systole  the  hardened  and  pointed  apex  slipped 
down  along  the  front  wall  of  the  chest,  somewhat  to  the  left  and  a  little  below  the 
lower  margin  of  the  wound,  whilst  in  the  diastolic  movement  the  apex  retreated 
upward  and  could  not  be  felt."  This  observation,  which  affords  valuable  con- 
firmatory evidence  of  the  systolic  elongation  of  the  heart,  is  not  ofl"ered  by  the 
reporter  as  such  ;  he  regarding  it  as  settled  that  the  vertical  diameter  of  the  organ 
is  shortened  in  the  systole. 

4 


50  ENLARGEMENT    OF    THE    HEART. 

pertaining  to  the  abdomen  may  remove  the  apex  to  the  left,  but 
without  lowering  it.  An  aneurismal  or  other  tumor  situated  above 
the  heart  may  give  rise  to  the  same  change  with  depression.  An 
emphysematous  left  lung  pushes  the  heart  downwards,  but  gene- 
rally towards  the  epigastrium,  often  giving  rise  to  an  impulse  in 
this  situation,  while  the  normal  apex-beat  is  suppressed.  These 
extrinsic  conditions  are,  of  course,  to  be  excluded  before  the  abnor- 
mal position  of  the  apex  can  be  regarded  as  a  sign  of  enlargement 
of  the  heart.  The  limits  of  variation  in  health,  in  different  posi- 
tions of  the  body,  are  to  be  borne  in  mind  in  deciding  whether  the 
situation  be  normal  or  abnormal.  If  the  patient  be  examined  in 
the  sitting  posture,  and  the  apex-beat  be  found  in  the  fifth  inter- 
costal space,  it  is  not  lower  than  natural ;  but  if  the  patient  lie  on 
the  back,  the  chances  are  about  equal  that  if  the  beat  be  in  that 
space  it  is  lowered ;  but  if  it  be  abnormally  lowered,  it  will  also  be 
removed  to  the  left  in  the  great  majority  of  cases.  With  reference 
to  its  relations  laterally,  it  may  be  within  half  an  inch  of  a  vertical 
line  passing  through  the  nipple,  or  three  and  a  half  inches  from  the 
median  line,  without  exceeding  the  range  of  healthy  variation.  If 
on  a  line  with  the  nipple,  or  four  inches  from  the  median  line,  its 
situation  is  abnormal,  provided  the  patient  be  either  sitting  or 
lying  on  the  back.  In  the  majority  of  the  cases  of  enlargement 
which  come  under  the  notice  of  the  physician,  it  is  found  without 
the  line  of  the  nipple. 

The  area  in  which  the  apex-beat  is  felt  (averaging  about  an  inch 
in  health)  is  extended  in  cases  of  enlargement  of  the  heart.  The 
extremity  of  the  organ  is  less  pointed  than  in  health ;  it  is  blunt  or 
rounded,  and  consequently  a  broader  surface  comes  into  contact 
with  the  thoracic  walls  during  the  systolic  impulse.  This  is  a  sign 
of  some  importance  taken  in  connection  with  other  signs  denoting 
enlargement  either  by  hypertrophy  or  dilatation. 

In  cases  of  hypertrophy  of  the  left  ventricle,  the  force  of  the 
apex-beat  is  abnormally  great  in  proportion  to  the  increased  thick- 
ness of  the  walls,  provided  that  the  form  of  the  apex  be  not  greatly 
altered,  the  muscular  power  of  the  organ  not  weakened,  or  the 
completeness  of  the  ventricular  contractions  not  prevented  by  con- 
traction at  the  aortic  orifice,  or  other  causes.  An  abnormal  force 
of  the  apex-beat  is  associated  with  change  in  situation  and  exten- 
sion of  the  area  in  which  the  beat  is  felt.  The  force  of  the  beat 
thus  associated  is  an  important  sign  as  showing  that  the  enlarge- 
ment is  due  to  hypertrophy  rather  than  to  dilatation,  or  that  the 


FORCE    OF    APEX-BEAT   IN    HYPERTROPHY.  51 

former   predominates.      la    proportion   as    the    left   ventricle    is 
hypertrophied  rather  than  dilated,  other  things  being  equal,  the 
force  of  the  beat  is  augmented.    Augmented  force  of  the  beat, 
however,  may  be  due  simply  to  increased  muscular  activity  of  the 
organ  without  enlargement.     The  heart  is  aS'ected  functionally  or 
dynamically  without  organic  disease.     The  beat  is  augmented  in 
the  same  manner  as  under  excitement  by  active  exercise  or  mental 
agitation.     How  is  it  to  be  determined  whether  the  abnormal  force 
of  the  beat  be  due  to  hypertrophy  or  simply  to  morbid  excitement 
of  the  organ  ?     The  sensation  in  the  latter  case  is  that  of  increased 
action,  and  in  the  former  case  of  increased  power,  of  the  impulsive 
movement.     This  distinction  is  generally  appreciable.     The  beat 
in  hypertrophy  is  felt  to  be  produced  by  a  powerful  contraction  of 
the  ventricle ;  the  impression  conveyed  by  the  touch  is  that  of  a 
prolonged,  sluggish,  as  well  as  strong  impulse.     In  mere  functional 
excitation,  the  beat  is  more  abrupt,  quick,  and  brief,  giving  the 
idea  of  violence  rather  than  of  strength.     The  distinction  is  import- 
ant, and  would  be  vastly  more  so  were  the  discrimination  to  rest 
solely  on  the  difference,  as  respects  the  force  of  the  beat.     But  in 
hypertrophy  there  are  the  coexisting  signs  of  enlargement  which 
are  wanting  in  an  afiection  simply  functional.     Increased  force  of 
the  apex-beat  is  by  no  means  a  constant  sign  of  hypertrophy.     On 
the  contrary,  the  beat  may  be  suppressed.     This  may  depend  in 
part  on  the  change  of  form  which  the  extremity  of  the  organ 
undergoes,  and   partly  on   the  weakness   incident  sometimes   to 
enlargement,  even  when  the  muscular  tissue  is  augmented.     The 
latter  belongs  to  a  late  period  in  the  progress  of  the  disease.     Sup- 
pression of  the  apex-beat  is  much  more  apt  to  occur  in  cases  of 
dilatation  than  in  cases  of  hypertrophy,  because  in  the  former  the 
extremity  of  the  organ  is  more  blunted  and  weakness  more  marked. 
Other  signs  of  cardiac  enlargement  and  hypertrophy  than  those 
relating  to  the  apex-beat  are  obtained  by  palpation.     Abnormal 
impulses  may  be  felt  in  other  situations  than  over  the  apex.    Occa- 
sionally, in  health,  in  addition  to  the  apex-beat  in  the  normal  situa- 
tion, an  impulse  is  appreciable  in  the  fourth  intercostal  space,  and, 
in  some  instances,  in  the  epigastrium  to  the  left  of  the  xiphoid  car- 
tilage,    A  double  impulse,  viz.,  in  the  fourth  and  fifth,  or  in  the 
fifth  and  sixth  intercostal  spaces,  is  not  unusual  in  cases  of  enlarge- 
ment, and  especially  enlargement  by  hypertrophy.     In  some  cases 
impulses  are  felt  in  three  and  even  in  four  intercostal  spaces.     In 
these  cases  the  lowest  point  of  impulse  is  the  farthest  removed  from 


52  ENLARGEMENT    OF    THE    HEART. 

the  median  line,  and  the  impulses  above  are,  severally,  situated 
nearer  the  sternum.  In  a  patient  under  observation  at  the  time  of 
writing,  impulses  are  felt  and  seen  in  the  fifth,  fourth,  third,  and 
second  intercostal  spaces.  The  impulse  in  the  fifth  intercostal  space 
is  situated  an  inch  without  a  vertical  line  passing  through  the 
nipple;  that  in  the  fourth,  is  just  within  the  nipple,  and  the  im- 
pulses in  the  third  and  second  spaces  are  near  the  left  margin  of 
the  sternum.^  The  explanation  of  these  additional  impulses  in 
cases  of  enlargement  is,  the  heart  being  in  contact  with  the  thoracic 
walls  over  a  larger  space  than  in  health,  in  other  words,  the  area 
of  the  superficial  cardiac  region  being  enlarged,  the  movements  of 
the  organ  are  communicated  to  the  yielding  spaces  between  the 
ribs.  This  does  not  take  place,  as  a  rule,  in  health,  in  consequence 
of  the  interposition  of  lung  save  over  a  comparatively  limited 
space.  The  impulsive  movements,  elsewhere  than  over  the  apex, 
are  not  always  coincident  with  the  ventricular  systole;  in  other 
words,  the  elevations  or  outward  motions  at  the  several  points  at 
which  the  movements  are  observed,  do  not  take  place  in  unison, 
but  in  some  instances  in  alternation.  Thus  when  movements  are 
felt  in  the  fourth  and  sixth  intercostal  spaces,  that  in  the  sixth  is 
the  apex-beat  and  systolic,  while  that  in  the  fourth  may  occur  with 
the  diastole  of  the  ventricles.  Alternation  of  the  impulsive  move- 
ments in  these  two  intercostal  spaces,  is  not  unfrequently  observed 
in  cases  of  hypertrophy.  The  superior  or  diastolic  movement  was 
called  by  Dr.  Hope  the  back-stroke  of  the  heart.  It  is  stated  that 
this  is  sometimes  observed  in  healthy  persons  when  the  heart  acts 
with  unusual  vigor.^  Generally  in  the  cases  in  which  a  diastolic 
movement  is  observed,  retraction  of  the  intercostal  space  takes 
place  during  the  ventricular  systole,  due  to  the  flattening  of  a 
portion  of  the  heart,  and  the  movement  of  impulsion  which  alter- 
nates with  the  apex-beat  is,  in  fact,  only  the  elevation  of  the  space 
to  the  level  from  which  it  was  depressed.  In  other  words,  the 
space  over  the  body  of  the  heart  yields  to  atmospherical  pressure 
and  follows  the  retreating  ventricular  walls  during  the  systole, 
resuming  its  level  when  the  heart  assumes  a  more  globular  form 
during  the  diastole.  The  impulsion  is  not  strong,  and  may  be 
visible  when  not  distinctly  felt.  In  the  case  just  referred  to  in 
which  four  distinct  points  of  impulse  are  observable,  the  impulsion 

'  Case  of  Bergmann.     Hospital  Records,  vol.  xiii. 

2  Bellingliam  on  Diseases  of  tlie  Heart.     Dublin,  1853.     Part  I.  p.  61. 


ADDITIONAL    IMPULSES    IN    HYPERTROPHY.  53 

in  the  fifth,  third  and  second  intercostal  spaces  appears  to  take 
place  during  the  systole,  and  that  in  the  fourth  intercostal  space 
during  the  diastole  of  the  ventricles.  The  three  former  are  stronger 
than  the  latter.  An  impulse  over,  or  a  little  below  the  base  of  the 
heart,  i.  e.,  in  the  third  and  possibly  in  the  second  intercostal  space, 
is  referable  to  the  expansion  of  the  upper  portion  of  the  organ 
during  the  systole.  The  fact  of  this  expansion  and  the  force  with 
which  it  takes  place  are  shown  by  grasping  the  heart  near  the  base 
in  a  living  animal.  A  strong  pressure  is  felt  when  the  ventricles 
contract.  It  is  not  difficult  to  understand  that  the  change  of  form 
at  the  base  should  communicate  an  impulsive  movement  to  the 
intercostal  space  when  the  heart  is  abnormally  uncovered  of  lung, 
and  also  in  some  instances  of  palpitation  without  organic  disease, 
when  the  action  of  the  heart  is  notably  augmented.  It  is  possible 
that,  in  some  instances,  the  dilatation  of  the  pulmonary  artery 
following  the  systole  of  the  ventricles,  or  the  shock  produced  by 
the  sudden  arrest  of  the  column  of  blood  in  consequence  of  the 
expansion  of  the  sigmoid  valves  during  the  ventricular  diastole, 
may  give  rise  to  an  impulsive  movement  which  may  be  felt  in  the 
second  left  intercostal  space.  Dr.  Sibson  states  that  a  diastolic 
impulse  is  sometimes  felt  in  this  situation  when,  from  pulmonary 
disease,  the  left  lung  recedes  at  this  point,  leaving  the  artery  unco- 
vered and  in  contact  with  the  parietes  of  the  chest.^  An  impulse 
situated  here,  referable  to  the  pulmonary  artery,  is  more  likely  to 
occur,  for  obvious  reasons,  in  cases  of  hypertrophy  of  the  right 
ventricle  and  when  there  exists  obstruction  to  the  pulmonary  cir- 
culation. Laennec  entertained  the  idea  that  an  impulse  on  the  left 
side  at  the  base  of  the  heart  was  sometimes  due  to  the  contraction 
of  the  left  auricle.  Aside  from  the  fact  that  the  greater  part  of  the 
auricle  is  covered  by  the  large  arteries  emerging  from  the  heart, 
and  the  improbability  of  its  ever  contracting  with  sufficient  force 
to  communicate  a  perceptible  impulse  to  the  walls  of  the  chest,  it 
is  difficult  to  understand  how  any  other  than  a  movement  of  retrac- 
tion can  accompany  its  systole.  It  seems  far  more  reasonable  to 
attribute  an  impulse  in  this  situation,  either  to  the  ventricles  or  to 
the  pulmonary  artery.  If  there  be  free  regurgitation  through  the 
mitral  orifice,  it  is  intelligible  that  the  retrograde  current  of  blood 
impelled  by  the  force  of  the  systole  of  the  left  ventricle  may  occa- 
sion an  impulse  over  the  auricle.     This  is  perhaps  the  explanation 

•  Medical  Anatomy. 


54:  ENLAKGEMENT    OF    THE    HEART. 

in  some  instances,  at  least,  in  which  an  auricular  impulse  has 
been  supposed  to  exist.  Dr.  Stokes  reports  a  case  in  which  an 
impulse  was  felt  on  the  right  side  of  the  sternum,  evidently,  from 
the  appearances  after  death,  due  to  a  retro-current  through  the 
tricuspid  orifice,  the  right  auricle  being  enormously  dilated  and  its 
walls  attenuated,^  It  is  evident  that  an  impulse  produced  in  this 
way  through  the  left  auricle  involves  the  supposition  of  auricular 
dilatation.  It  is  indeed  possible  that  without  insufficiency  of  the 
mitral  or  tricuspid  valves,  an  impulse  may  be  produced  by  the 
momentum  communicated  to  the  blood  contained  within  a  dilated 
and  distended  auricle  by  the  backward  pressure  of  these  valves 
during  the  ventricular  systole. 

It  is  to  be  borne  in  mind  that  the  occurrence  of  movements  in 
the  intercostal  spaces,  impulsive  or  retractive,  involves  contingencies 
irrespective  of  cardiac  disease.  They  are  more  likely  to  occur  in 
persons  who  have  flattened  chests  and  long  sternums  than  in  those 
with  a  thoracic  conformation  the  opposite  of  this.  They  require  a 
certain  thinness  of  the  parietes  of  the  chest,  and  are  more  marked 
in  proportion  as  the  thoracic  walls  are  attenuated.  They  may  be 
obvious  when  the  heart  is  excited,  and  not  appreciable  when  the 
organ  acts  feebly.  They  may  be  due  to  abnormal  conditions  per- 
taining to  the  lungs,  the  heart  remaining  sound.  They  are  ob- 
served in  some  instances  in  which  the  pulmonary  substance  is 
withdrawn  from  the  heart,  as  after  the  absorption  of  liquid  effusion 
in  pleurisy  affecting  the  left  side  and  in  some  cases  of  tuberculosis. 
An  effect  of  these  affections  is  often  to  leave  an  enlarged  area  of 
the  heart's  surface  in  contact  with  the  walls  of  the  chest,  and,  under 
these  circumstances,  the  motions  of  the  organ  may  communicate 
corresponding  movements  to  the  intercostal  spaces.  Hence,  impul- 
sive movements  elsewhere  than  over  the  apex  of  the  heart  are 
never  signs  of  enlargement,  unless  associated  with  altered  situation 
of  the  apex-beat  and  other  signs  indicating  that  the  bulk  of  the 
organ  is  increased. 

The  conformation  of  the  chest  in  some  persons  is  such  that  an 
impulse  referable  to  the  heart  is  felt,  in  health,  in  the  epigastrium 
by  directing  the  fingers  upwards  and  outwards  beneath  the  false 
ribs  on  the  left  side.     In  the  majority  of  persons  the  organ  is  too 

'  On  Diseases  of  the  Heart  and  Aorta,  Am,  ed.,  p,  290.  Dr.  Stokes  attributes  the 
impulse  over  the  dilated  auricle,  in  that  case,  to  the  auricular  contraction ;  but  as 
he  states  that  it  was  synchronous  with  the  ventricular  systole  or  the  first  sound  of 
the  heart,  it  seems  clearly  to  have  been  due  to  a  regurgitant  current. 


IMPULSE    IN    EPIGASTRIUM.  55 

far  removed  for  its  action  to  be  appreciable  in  this  situation. 
Cardiac  impulse  in  the  epigastrium  is  therefore  usually,  but  not 
invariably,  a  sign  of  disease.  As  a  morbid  sign,  it  denotes  either 
enlargement  of  the  heart  or  displacement  in  a  downward  direction. 
It  is  a  sign  by  no  means  present  in  most  cases  of  enlargement  of 
the  heart.  The  oblique  position  of  the  heart  and  the  resistance 
offered  by  the  diaphragm  and  the  left  lobe  of  the  liver  prevent 
much  descent  towards  the  epigastrium.  These  circumstances  apply, 
as  has  been  seen,  measurably,  to  cases  in  which  the  enlargement 
predominates  in  the  right  as  well  as  the  left  ventricle.  But  it  is 
undoubtedly  true  that  an  impulse  in  this  situation  is  more  likely  to 
occur  as  a  result  of  enlargement  of  the  right  than  of  the  left  ven- 
tricle. When  it  proceeds  from  a  cardiac  affection,  it  may  be  con- 
sidered as  affording  strong  presumptive  evidence  that  the  right 
ventricle  is  enlarged.  A  strong  impulse,  under  these  circumstances, 
goes  to  show  that  the  enlargement  involves  not  merely  dilatation, 
but  hypertrophy.  The  question  to  be  first  settled  is.  Does  it  pro- 
ceed from  increased  size  of  the  heart?  This  question  may  be 
settled  frequently  by  reference  to  the  apex-beat.  If  the  beat  be  in 
its  normal  situation,  and  there  are  no  signs  of  enlargement,  the 
impulse  in  the  epigastrium  is  probably  normal.  It  is  not  a  sign  of 
disease.  But  if  the  apex-beat  be  removed  to  the  left  of  its  normal 
position,  it  becomes  a  sign  of  enlargement  of  the  right  ventricle. 
When  this  is  the  case,  other  signs  of  enlargement  will  also  be 
present.  The  diagnostic  value  of  the  sign,  thus,  when  it  is  attri- 
butable to  a  cardiac  affection,  consists  in  its  indicating  that  the 
right  ventricle  is  the  seat  of  enlargement.  When  it  is  determinable 
that  the  epigastric  impulse  is  due  to  cardiac  enlargement,  the  extent 
of  the  impulse  will,  in  some  measure,  be  an  index  of  the  amount  of 
increase  of  the  bulk  of  the  right  ventricle,  and  the  power  of  the 
impulse  will  be  in  proportion  as  the  enlargement  is  by  hypertrophy, 
provided  that  the  organ  is  not  weakened  from  any  cause,  or  pre- 
vented from  contracting  completely.  The  impulse  is  communicated 
in  some  instances  not  only  to  the  epigastrium,  but  to  the  lower  part 
of  the  sternum,  and  it  is  sometimes  sufficient  to  cause  a  movement 
perceptible  to  the  eye  and  touch,  which  extends  over  the  site  of  the 
liver.  When  due  to  displacement  of  the  heart,  in  the  great  majority 
of  instances  it  is  dependent  on  emphysema  affecting  the  left  lung. 
The  dilated  lung  presses  the  heart  downwards,  overcoming  the 
resistance  offered  by  the  diaphragm  and  liver,  and  the  action  of 
the  right  ventricle  is  felt  in  the  epigastrium.     The  signs  and  symp- 


56  ENLARGEMENT    OF    THE    HEART. 

toms  of  emphysema  are  sufficient  to  establish,  the  fact  that  this 
cause  of  displacement  exists.  The  apex-beat,  under  these  circum- 
stances, is  frequently  or  generally  wanting.  Emphysema,  however, 
induces  enlargement  of  the  heart,  seated  primarily  and  especially 
in  the  right  ventricle.  The  epigastric  impulse,  tiierefore,  may  be 
due  to  both  causes  combined,  viz.,  enlargement  and  displacement. 
To  determine  the  proportion  which  each  bears  in  the  production  of 
the  sign  is  not  easy.  If  the  boundaries  of  the  heart  are  determin- 
able by  percussion,  or  if  the  situation  of  the  apex-beat  can  be 
ascertained,  this  point  may  be  settled  with  much  precision.  In 
examining  the  epigastrium  with  reference  to  the  evidence  of  car- 
diac enlargement,  it  is  important  not  to  confound  an  impulse 
undoubtedly  referable  to  the  heart  with  pulsations  often  felt  in 
that  situation  which  are  only  indirectly  attributable  to  the  heart's 
action.  In  some  thin  persons,  the  beating  of  the  descending  aorta 
may  be  here  felt ;  and  in  connection  with  hysteria  and  other 
nervous  affections,  especially  when  accompanied  by  gastric  tym- 
panites, strong  pulsations  are  perceived  in  the  epigastrium,  which 
are  said  not  to  be  uniformly  synchronous  with  the  heart's  move- 
ments, and  the  mechanism  of  which  it  is  not  easy  to  explain.  It  is 
not  difficult  by  means  of  palpation  either  to  trace  these  pulsations 
directly  to  the  heart  or  to  isolate  them  from  the  latter. 

The  action  of  the  heart  is  frequently  attended  by  a  shock  felt  by 
the  hand  or  the  head  applied  over  the  praecordia.  Sensible  move- 
ments are  also  sometimes  communicated  to  the  ribs,  as  well  as  the 
intercostal  spaces,  and  they  may  extend  over  the  preecordia.  When 
the  heart  is  tranquil,  in  health,  a  shock  is  rarely  if  ever  perceived. 
The  fifth  rib  is  occasionally  slightly  raised  by  the  movements  of 
the  apex  during  the  systole.  In  disease,  these  effects  of  the  heart's 
action  are  often  marked.  A  perceptible  and  more  or  less  forcible 
shock  attends  certain  palpitations  which  are  merely  functional. 
The  heart  appears  to  act  with  violence.  It  seems  to  knock  against 
the  ribs.  The  sensation,  in  some  instances,  is  as  if  the  chest  were 
struck  with  a  hammer.  The  patient  is  painfully  sensible  of  the 
force  of  the  impulsion,  while,  in  health,  if  the  heart  be  not  excited, 
its  movements  take  place  without  the  mind  being  cognizant  of 
them.  The  violence  of  the  action  is  shown  by  the  movements  of 
the  body,  of  the  dress,  of  the  bedclothes.  The  instances  related  of 
fracture  of  the  ribs  and  detachment  of  the  costal  cartilages  by  the 
force  of  the  heart's  action  are  doubtless  apocryphal,  but  the  shock 
is  sometimes  very  great.     It  may  be  limited  to  the  apex  or  felt  at 


HEAVING    IMPULSE    IN    HYPEKTEOPHY.  57 

the  base,  and,  indeed,  over  the  whole  pr^cordia.  Alone,  the  shock, 
however  violent,  only  indicates  excited  action  of  the  heart.  It  does 
not,  of  necessity,  imply  organic  disease.  It  may  be  due  simply  to 
the  fact  that  the  heart  acts  with  spasmodic  or  convulsive  quickness 
and  force.  It  is  represented  by  the  intense  action  incident  to  fear 
and  some  other  emotions.  If  it  be  inorganic  or  functional,  it  is 
usually  temporary,  unattended  by  physical  signs  denoting  organic 
lesions,  and  characterized  by  circumstances  which  will  be  hereafter 
considered  as  distinctive  of  nervous  disorder  or  palpitation.  Or- 
ganic disease,  it  is  true,  is  often  attended  by  violent  action  of  the 
heart,  but  the  significance  of  the  latter  as  a  sign  of  the  former 
depends  on  the  coexistence  of  other  signs  which  are  more  unequi- 
vocal ;  and,  on  the  other  hand,  organic  disease  is  often  present 
when  the  heart's  action  is  more  feeble  than  in  health.  A  strong 
heaving  movement  of  the  ribs  or  the  prrecordia  is,  however,  highly 
significant  of  enlargement  by  hypertrophy.  This  is  quite  different 
from  the  shock  which  has  just  been  described.  It  is  a  compara- 
tively sluggish,  prolonged,  powerful  elevation  of  the  thoracic  walls. 
The  head,  applied  as  in  immediate  auscultation,  is  raised,  and,  by 
the  hand  placed  over  the  praecordia,  the  heart  is  felt  to  act  with 
abnormal  strength.  The  shock,  due  to  intense  functional  excite- 
ment, proceeds  merely  from  exaggerated  action  of  the  heart ;  the 
heaving  movement  in  hypertrophy  involves,  in  addition,  increased 
power  of  the  muscular  contractions  of  the  organ.  Moreover,  in 
the  latter  case,  the  surface  of  the  heart  being  in  contact  with  the 
thoracic  walls  over  a  larger  area,  the  extent  of  the  impulsive 
movement  is  greater.  The  distinction  just  drawn  is  the  same  as 
has  been  already  pointed  out  in  contrasting  the  prolonged,  power- 
ful apex-beat  of  a  hypertrophied  heart  with  the  smart,  sharp, 
violent  impulse  which  only  indicates  excited  activity  of  the  ven- 
tricular systole.  The  distinction  in  both  instances  is  practically 
important,  but  in  discriminating  between  functional  disorder  and 
organic  disease,  in  practice,  the  diagnostician  will,  of  course,  be 
guided  by  the  absence  or  concurrence  of  other  signs.  It  is  hardly 
necessary  to  state  that  heaving  of  the  prgecordia  is  not  uniformly 
present  in  hypertrophy.  The  presence  of  this  sign  involves,  as  a 
condition,  a  degree  of  functional  activity  proportionate  to  the 
augmented  thickness  of  the  ventricular  walls;  in  other  words,  it 
will  not  be  present  if  the  muscular  power  of  the  heart  be  weakened 
from  any  cause,  notwithstanding  the  augmented  bulk  of  the  organ. 
Clinical  observation,  in  fact,  shows  that  a  heaving  impulse  is  often 


58  EXLARGEMEXT    OF    THE    HEART. 

wanting  in  cases  of  hypertrophy.  While,  therefore,  the  presence 
of  this  sign  is  evidence  of  the  existence  of  hypertrophy,  its  absence 
is  by  no  means  proof  that  hypertrophy  does  not  exist. 

3.  Abnormal  modifications  of  the  heart-sounds;  diminished  extent  and 
degree  of  the  respiratory  murmur  and  of  vocal  resonance  within  the 
lyrsecordia,  as  determined  by  auscultation. 

The  clinical  importance  of  abnormal  modifications  of  the  heart- 
sounds  has  relation  more  to  valvular  affections  than  to  enlargement 
of  the  heart.  They  are,  however,  by  no  means  unimportant  in 
connection  with  the  latter.  And  here,  as  in  treating  of  the  physical 
signs  embraced  in  the  two  classes  already  considered,  it  will  be 
necessary  to  premise  some  account  of  the  heart-sounds  in  health. 
To  enter  into  a  discussion  of  the  numerous  theories  which  have 
been  advanced  with  regard  to  the  mechanism  of  these  sounds, 
would  be  tedious  and  unprofitable,  as  well  as  foreign  to  the  prac- 
tical character  of  this  work.  I  shall  limit  myself  to  a  concise  state- 
ment of  points  which  are  essential  as  preliminary  to  the  study  of 
the  phenomena  of  disease ;  and  I  shall  devote  to  these  less  space 
in  consequence  of  having  recently  considered  them  in  a  special 
publication,  to  which  the  reader  is  referred  for  a  fuller  exposition 
of  the  subject.' 

The  two  heart-sounds,  which  together  form  the  beat  or  revolu- 
tion of  the  heart,  are  called  the  first  and  second,  or  the  systolic 
and  diastolic  sound.  By  the  latter  terms,  it  is  implied  that  the 
first  sound  occurs  during  the  systole  and  the  second  sound  during 
the  diastole  of  the  ventricles.  This,  although  called  in  question 
by  some,  may  be  assumed  as  sufficiently  established.^  These  sounds, 
respectively,  have  their  maximum  of  intensity,  and  their  characters 
are  best  studied  in  different  situations,  viz.,  the  first  sound  over  the 
point  where  the  apex-beat  is  felt,  and  the  second  sound  just  above 
the  base  of  the  heart,  in  the  intercostal  space  between  the  second 
and  third  ribs  near  to  the  sternum.  Studied  in  these  different 
situations,  the  two  sounds  differ  as  respects  duration,  pitch,  and 
quality.     The  first  sound,  over  the  apex,  is  longer,  lower,  and  has 

•  On  the  Clinical  Studj  of  the  Heart-Sounds  in  Health  and  Disease.  Prize  Essay. 
Transactions  of  the  American  Medical  Association,  vol.  xi.,  1S58. 

^  M.  Beau  contends  that  the  first  sound  is  due  to  the  auricular  contractions. 
Op.  cit. 


HEAKT-SOUNDS    IN    HEALTH.  59 

a  booming^  quality.  The  second  sound,  in  the  second  intercostal 
space  near  the  sternum  on  either  side,  is  shorter,  more  acute,  and 
has  a  flapping  or  valvular  quality.  These  differences  in  characters 
between  the  two  sounds  are  generally  well  marked  when  the  com- 
parison is  made  in  the  different  situations  mentioned,  but,  as  will 
be  seen  presently,  they  are  much  less  marked  in  other  situations 
within  the  prsecordia.  The  sources  of  each  of  the  sounds,  and  the 
parts  concerned  in  its  production,  are  important  to  be  considered. 
"With  reference  to  these  and  other  points,  we  will  notice  each  sound 
separately,  commencing  with  the  second  sound. 

The  second  sound  succeeds  the  first  after  an  interval  extremely 
brief,  but,  w^hen  the  beats  of  the  heart  are  not  much  accelerated, 
distinctly  appreciable.  It  is  estimated  that  the  duration  of  this 
interval  and  the  second  sound  combined  is  equal  to  that  of  the  first 
sound,  or  of  the  longer  interval  which  separates  the  second  sound 
from  the  succeeding  first  sound,  the  latter  interval  and  the  first 
sound  being  about  equal  in  duration.  This  sound,  i.  €.,  the  second, 
as  already  stated,  is  best  studied  just  above  the  base  of  the  heart, 
in  the  space  between  the  second  and  third  ribs,  near  to  the  sternum. 
If  the  second  sound  be  compared  on  the  two  sides  of  the  sternum, 
a  difference  in  pitch  and  other  characters  is  generally  apparent.  On 
the  right  side  the  sound  is  more  acute,  more  abrupt,  louder,  and 
apparently  nearer  the  ear.  These  differences,  taken  in  connection 
with  the  anatomical  relations  of  the  aorta  and  pulmonary  artery  in 
these  situations,  and  also  with  clinical  facts  pertaining  to  disease, 
warrant  the  conclusion  that,  when  a  disparity  exists,  the  sound  on 
the  left  side  emanates  from  the  pulmonary  artery,  and  that  on  the 
right  side  from  the  aorta.  The  sound  in  both  situations  has  an 
unmixed,  valvular  quality,  and,  in  view  of  the  results  of  experi- 
ments made  on  living  animals,  and  the  effects  of  disease,  it  may  be 
assumed  that  the  valves  of  the  aorta  and  pulmonary  artery  are  the 
parts  immediately  concerned  in  its  production.  There  is,  then,  a 
pulmonary  second  sound,  due  to  the  expansion  of  the  valves  of  the 
pulmonary  arter}^  succeeding  the  ventricular  systole,  and  an  aortic 
second  sound,  referable  to  the  semilunar  valves  of  the  aorta.  The 
second  sound  of  the  heart  presents  the  characters  of  that  due  to  the 
pulmonary  valves,  at  the  inferior  border  of  the  organ,  i.  e.,  just 
above  the  xiphoid  cartilage  in  some  persons ;  occasionally,  also,  in 

'  The  term  booming,  borrowed  from  Dr.  Walshe,  has  not  a  very  definite  signifi- 
cation ;  but  expresses  a  difference  in  quality  difficult  to  be  described,  although 
easily  appreciated  by  the  ear. 


60  ENLARGEMENT    OF    THE    HEART. 

the  third  intercostal  space  on  the  left  side  and  over  the  body  of  the 
heart,  within  the  superficial  cardiac  region.  Elsewhere,  within  the 
prrecordia,  and  at  points  removed  from  the  pmecordia,  wherever  the 
second  sound  is  heard,  it  presents  the  characters  distinctive  of  the 
sound  produced  at  the  aortic  orifice.  These  facts  are  ascertained 
by  comparing,  in  a  sufficient  number  of  healthy  persons,  the  second 
sound,  as  heard  at  different  points,  with  that  heard  in  the  second 
intercostal  space  on  the  right  and  left  side.  It  follows  from  the 
facts  just  stated  that  the  aortic  second  sound  is  much  more  intense 
and  widely  diffused  than  the  pulmonary,  the  latter,  in  some  persons, 
being  distinguishable  alone  in  the  second  intercostal  space  on  the 
left  side ;  sometimes,  indeed,  the  aortic  sound  predominates  even  in 
that  situation.  The  second  sound  of  the  heart  maintains  its  distinct- 
ive characters  of  pitch,  duration,  and  valvular  quality,  unaffected 
by  the  causes  which  affect  the  movements  of  the  heart  within  the 
limits  of  health,  such  as  exercise,  mental  agitation,  etc.  Its  intensity 
even  is  not  much  affected  by  these  causes.  These  facts  show  its 
unmixed  character,  in  other  words,  that  it  consists  of  a  single 
element  only,  a  valvular  element,  in  this  res|)ect  differing  from  the 
first  sound  of  the  heart. 

The  first  sound  of  the  heart,  studied  at  the  situation  where  its 
intensity  is  greatest,  viz.,  over  the  apex  of  the  organ,  is  a  mixed 
sound.  In  this  situation,  it  is  usually  accentuated^  that  is,  in  the 
succession  of  the  two  sounds  the  stress  falls  upon  the  first,  while  at 
the  base  of  the  heart,  and  at  other  points,  the  accent  is  on  the 
second  sound.  The  mixed  nature  of  the  first  sound  is  shown  by 
the  difference  which  it  presents  on  auscultation  over  the  apex,  and 
at  other  points  within  the  prsecordia ;  by  contrasting  its  characters 
as  heard  when  the  stethoscope  is  firmly  placed  directly  on  the  sur- 
face of  the  chest  with  those  which  it  presents  when  some  soft 
material  is  interposed  between  the  instrument  and  integument,  or 
when  the  instrument  is  imperfectly  applied ;  by  auscultating  over 
the  apex  when  the  person  examined  is  placed  in  different  positions, 
and  taking  into  consideration  modifications  incident  to  certain 
diseases  and  peculiar  to  certain  persons  in  health.'  The  clinical 
study  of  this  sound  in  health  and  disease  leads  to  the  conclusion 
that  it  is  composed  chiefly  of  two  different  elements.  One  of  these 
elements  consists  of  a  valvular  sound,  due  to  the  action  of  the 

'  In  the  prize  essay  already  referred  to  {Trans.  Am.  Med.  Association,  vol.  xi., 
1858),  the  author  gives  a  full  account  of  the  results  of  the  clinical  study  of  this 
sound  under  the  different  circumstances  mentioned  above. 


HEAET-SOUNDS    IN    HEALTH.  61 

mitral  and  tricuspid  valves.  The  other  element,  in  the  author's 
opinion,  proceeds  from  the  movement  of  the  apex  of  the  heart 
against  the  thoracic  walls.  In  a  practical  point  of  view,  however, 
it  is  unimportant  whether  the  latter  element  be  thus  explained  or 
whether  it  be  accounted  for  on  the  hypothesis  of  a  sound  adequate 
to  its  production,  due  directly  to  muscular  contraction.  Eeferring 
it  to  the  movement  of  the  apex  against  the  thoracic  walls,  this 
element  may  be  called  the  element  of  impulsion^  and  the  other  ele- 
ment the  valvular  element}  These  names  will  be  employed  in  this 
work  to  distinguish  from  each  other  the  two  elements  composing 
the  first  sound. 

These  two  elements  of  the  first  sound  are  combined  in  different 
proportions  in  different  situations  in  which  auscultation  is  practised, 
in  different  positions  of  the  body,  and  under  different  circumstances 
pertaining  to  disease.  At  certain  points,  the  element  of  impulsion 
may  be  eliminated,  leaving  the  valvular  element  alone  present.  The 
element  of  impulsion  predominates  and  drowns  the  valvular  ele- 
ment, often  on  auscultation  over  the  apex.  It  predominates,  as  a 
rule,  over  the  body  of  the  heart.  At  the  base  of  the  heart  the 
valvular  element  frequently  predominates.  At  the  left  border  of 
the  heart,  over  the  left  nipple,  the  valvular  element  predominates, 
and,  on  carrying  the  stethoscope  to  the  left  of  this  point  for  a 
greater  or  less  distance,  the  element  of  impulsion  is  eliminated,  and 
the  valvular  element  remains,  leaving  the  sound  as  purely  valvular 
in  quality  and  as  short  as  the  second  sound.  The  valvular  element 
predominates  generally  at  the  right  border  of  the  heart  and  at  all 
the  points  removed  from  the  pr^ecordial  region  where  the  first 
sound  is  appreciable.  These  facts,  established  by  the  clinical  study 
of  the  heart-sounds  in  health,  show  that,  although  the  element  of 
impulsion  predominates  over  the  apex  and  body,  the  valvular 
element  alone  is  much  diffused  beyond  the  limits  of  the  organ, 

'  Discussion  of  this  opinion,  respecting  tlie  mechanism  of  the  element  of  impul- 
sion of  the  first  sound,  is  waived  in  this  work.  The  reader  is  referred  to  the 
author's  prize  essay  on  the  clinical  study  of  the  heart-sounds  for  the  grounds  on 
which  the  opinion  is  entertained,  I  will  simply  add  here  that  the  experiment  of 
placing  Cammann's  stethoscope  over  the  naked  heart,  when  exposed  in  a  living 
animal,  seems  to  me  sufficient  to  disprove  the  hypothesis  that  muscular  contrac- 
tion furnishes  an  element  of  the  first  sound.  The  first  sound  in  this  experiment 
is  intensely  valvular.  This  sound  sometimes  has  a  similar  intense  valvular 
quality,  in  cases  of  great  functional  excitement  of  the  organ,  when  the  stethoscope 
is  applied  on  the  chest  over  the  point  of  apex-beat,  the  element  of  impulsion 
heing,  from  some  cause,  wanting. 


62  ENLARGEMENT    OF    THE    HEART. 

The  valvular  element  is  less  intense  than  the  second  sound,  the 
latter  being  often  heard  in  situations  to  which  the  former  is  not 
transmitted,  viz.,  on  the  lateral  surfaces  of  the  chest,  in  the  right 
infra-clavicular  region,  and  over  the  back. 

The  valvular  element  of  the  first  sound,  as  stated  already,  is  due 
to  the  action  of  the  mitral  and  tricuspid  valves.  Is  the  sound 
emanating  from  each  of  these  valves  ever  distinguishable  from  the 
other  ?  Clinical  observation  warrants  an  affirmative  answer  to  this 
inquiry.  Over  the  inferior  border  of  the  heart,  near  the  xiphoid 
cartilage,  this  element  frequently  differs  in  pitch  from  the  same 
element  when  heard  in  the  same  person  at  or  without  the  left 
nipple.  This  may  be  considered  as  sufficient  to  render  it  at  least 
highly  probable  that  the  source  of  the  sound  in  the  latter  situation 
is  at  the  mitral,  and  in  the  former  situation  at  the  tricuspid  valves. 
A  striking  point  of  disparity  between  the  first  and  second  sound 
of  the  heart  relates  to  the  extent  of  variation  in  intensity  in  differ- 
ent persons,  and  in  the  same  person  under  different  circumstances 
within  the  limits  of  health,  as  well  as  in  connection  with  disease. 
The  first  sound  varies  considerably  in  intensity  according  to  the 
energy  with  which  the  heart  contracts,  and  according  to  the  pos- 
ture assumed ;  it  is  often  feeble  when  the  person  lies  on  the  back  as 
compared  with  intensity  in  the  sitting  posture,  or  lying  on  the  left 
side.  The  second  sound,  on  the  other  hand,  undergoes  little  change 
in  intensity  under  these  and  other  circumstances,  irrespective  of 
morbid  conditions.  The  variation  to  which  the  first  sound  is  liable 
relates  chiefly  to  the  element  of  impulsion.  The  valvular  element, 
like  the  second  sound  of  the  heart,  is  not  subject  to  much  variation 
in  intensity,  exclusive  of  disease. 

The  relatively  greater  duration  of  the  first  sound  of  the  heart,  as 
compared  with  the  second  sound,  depends  on  the  element  of  impul- 
sion. In  proportion  as  this  element  is  predominant  is  the  sound 
prolonged ;  and,  on  the  other  hand,  whenever  this  element  i*s 
eliminated,  the  first  sound  is  no  longer  than  the  second.  The 
interval  between  the  first  and  second  sound  is  determined  by  the 
length  of  the  first  sound.  This  interval  is  shortened  in  proportion 
as  the  first  sound  is  prolonged,  and  it  is  lengthened  in  proportion 
as  the  element  of  impulsion  of  the  first  sound  is  impaired  or 
eliminated. 

The  foregoing  brief  account  of  the  heart-sounds  in  health  em- 
braces, as  concisely  as  possible,  the  more  important  of  the  conclu- 


HEAET-SOUNDS    IN    HYPEETROPHY.  63 

sions  deduced  from  the  results  of  the  analysis  of  the  phenomena 
obtained  by  auscultation  in  the  examination  of  twenty-five  persons 
presumed  to  be  entirely  free  from  disease,  the  phenomena  being 
carefully  noted  at  the  time  of  the  examination.  For  a  fuller 
account  of  these  results,  the  reader  is  referred  to  the  publication 
already  alluded  to.  It  remains  now  to  notice  the  modifications  of 
the  heart-sounds  observed  in  connection  with  hypertrophy  of  the 
heart.  The  modifications  significant  of  hypertrophy,  difl'er  mate- 
rially from  those  which  pertain  to  dilatation.  The  former  relate  to 
the  present  subject.  The  latter  will  be  noticed  in  another  section 
in  connection  with  enlargement  by  dilatation. 

Hypertrophy  of  the  left  ventricle  tends  to  exaggerate  the  element 
of  impulsion  of  the  first  or  systolic  sound  so  long  as  the  muscular 
power  of  the  heart  remains  unimpaired.  The  impulsive  movements 
of  the  apex  against  the  walls  of  the  chest,  ccetens  paribus,  are  pro- 
portionate to  the  hypertrophy  of  this  ventricle.  Exceptions  to  this 
rule  occur  when  the  form  of  the  organ  is  so  changed  that  the  apex 
ceases  to  come  into  contact  with  the  thoracic  walls,  or  when,  owingr 
to  muscular  weakness,  the  impulsive  movements  are  diminished 
instead  of  being  increased.  All  observers  have  remarked  that  in 
cases  of  hypertrophy,  while  the  muscular  energy  of  the  heart  is 
proportionate  to  its  increased  bulk,  the  first  sound  is  notably  dull 
and  prolonged.  The  dulness  and  prolongation  of  this  sound,  as 
compared  with  the  second,  in  health,  are  due  to  the  element  of 
impulsion.  It  is,  therefore,  quite  intelligible  that  when  the  impul- 
sive movements  are  increased,  the  effects  on  this  sound  are  abnor- 
mal dulness  and  prolongation,  as  well  as  exaggerated  intensity. 
Mere  exaggeration  of  this  sound  is  by  no  means  in  itself  significant 
of  hypertrophy.  Increased  muscular  action  of  the  heart,  as  in 
some  instances  of  functional  disorder,  renders  the  sound  abnormally 
intense,  so  that  it  is  sometimes  appreciable  at  a  distance  from  the 
chest,  and  painfully  perceived  by  the  patient.  Both  elements  of 
the  sound,  under  these  circumstances,  are  exaggerated.  This  is 
also  true  in  cases  of  pure  hypertrophy,  i.  e.,  uncomplicated  with 
valvular  lesions ;  but  in  hypertrophy  the  element  of  impulsion  is 
relatively  more  exaggerated  than  the  valvular  element,  and  hence, 
when  the  dulness  and  prolongation  are  marked,  as  well  as  the 
increased  intensity,  the  modification  becomes  significant  of  this 
affection.  Modifications  affecting  the  valvular  element  of  the  first 
sound  are  of  importance  chiefly  in  connection  with  the  diagnosis  of 


6-1:  ENLARGEMENT    OF    THE    HEART. 

valvular  lesions.      The  modifications  significant  of  hypertrophy 
relate  more  especially  to  the  element  of  impulsion.^ 

Modifications  of  the  second  or  diastolic  sound,  incident  to  hyper- 
trophy, may  affect  the  aortic  and  the  pulmonary  sound  separately 
or  combined.  The  pulmonary  and  the  aortic  sound  are  in  relation 
respectively  to  the  right  and  left  ventricle.  The  expansion  of  the 
semilunar  valves  succeeding  the  ventricular  systole  is  due,  in  a 
great  measure  at  least,  to  the  systolic  contraction  of  the  ventricles. 
The  column  of  blood  propelled  from  the  ventricles  dilates  the  aorta 
and  pulmonary  artery,  and  the  recoil  due  to  the  elasticity  of  the 
coats  of  these  vessels  during  the  ventricular  diastole  gives  rise  to 
the  expansion  of  the  valves,  which  occasions  the  second  sound. 
This  is  the  explanation  now  generally  received  of  the  mode  in 
which  the  expansion  of  the  valves  is  produced.  Whether  another 
agency  be  not  involved  in  the  production  of  the  second  sound,  viz., 
an  active  diastolic  expansion  of  the  ventricles,  is  a  matter  of  ques- 
tion. The  force  derived  from  the  elasticity  of  the  arteries,  if  not 
the  sole  agency,  is,  at  all  events,  the  most  important  in  causing  the 
expansion  of  the  valves.  This  force,  it  is  obvious,  other  things 
being  equal,  is  proportionate  to  the  power  of  the  ventricular  sys- 
tole. The  dilation  of  the  aorta  and  pulmonary  artery  is  greater 
the  more  powerful  the  contractions  of  the  ventricles,  and  the  re- 
bound of  the  arterial  coats  is  stronger  the  more  the  vessels  have 
been  dilated.  Hence,  the  intensity  of  the  second  sound  of  the  heart 
represents  the  power  of  the  systolic  contractions  of  the  ventricles ; 
and  the  aortic  and  the  pulmonary  sound  respectively  represent,  in 
this  respect,  the  left  and  the  right  ventricle.  The  two  ventricles, 
as  has  been  seen,  mtiy  become  enlarged  by  hypertrophy  separately, 
as  well  as  conjointly ;  and  when  both  are  affected  the  enlargement 
of  one  generally  predominates  over  that  of  the  other.  It  might, 
therefore,  be  expected,  and  clinical  observation  shows  that  an 
abnormal  intensity  of  the  aortic  and  the  pulmonary  sound  sepa- 

'  My  clinical  observations  have  led  me  to  regard  exaggeration  of  the  tricuspid 
portion  of  the  valvular  element  of  the  first  sound  as  evidence,  in  some  cases,  of 
hypertrophy  of  the  right  ventricle.  To  determine  the  fact  of  its  exaggeration,  the 
valvular  element  of  the  first  sound  is  to  he  compared  at  the  inferior  boundary  of 
the  heart,  near  the  xiphoid  cartilage,  with  this  element  at  the  left  border  of  the 
heart  at  or  without  the  left  nipple.  In  health,  this  element  of  the  first  sound  is 
notably  more  feeble  in  the  former  than  in  the  latter  situation.  If  the  valvular 
sound  be  equally  or  more  marked  at  the  inferior  boundary  of  the  heart,  provided 
the  mitral  valves  are  sound,  it  is  evidence  that  hypertrophy  of  the  right  ventricle 
exists,  if  other  signs  of  cardiac  enlargement  are  at  the  same  time  present. 


HEAET-SOUNDS  IX  HYPERTROPHY.  65 

ratelj,  may  become  a  sign  of  hypertrophy  affecting,  in  the  one 
case,  the  left,  and,  in  the  other  case,  the  right  ventricle. 

Hypertrophy  of  the  left  ventricle  gives  rise  to  exaggerated 
intensity  of  the  aortic  second  sound,  i.  e.,  the  sound  having  its 
maximum  of  intensity  in  the  second  intercostal  space  on  the  right 
side  of  the  sternum,  provided  this  effect  be  not  prevented  by 
attendant  circumstances,  which  are  of  frequent  occurrence.  Lesions 
affecting  the  aortic  valves,  diminished  elasticity  of  the  aorta  from 
disease  of  its  coats,  contraction  at  the  mitral  orifice,  or  mitral  re- 
gurgitation, both  lessening  the  column  of  blood  propelled  by  the 
ventricle  into  the  aorta,  are  circumstances  which  obviously  stand 
in  the  way  of  an  abnormal  increase  of  the  aortic  second  sound 
proportionate  to  the  augmented  power  of  the  ventricle.  Hyper- 
trophy of  the  left  ventricle  is  seldom  altogether  devoid  of  these 
circumstances.  In  point  of  fact,  it  is  only  in  the  rare  instances  of 
uncomplicated  hypertrophy  of  this  ventricle  that  the  aortic  second 
sound  is  notably  exaggerated.  As  a  physical  sign,  therefore,  it  has 
very  little  value. 

Hypertrophy  of  the  right  ventricle,  on  the  other  hand,  is  seldom 
associated  with  circumstances  preventing  its  effect  on  the  pulmonary 
second  sound,  ?*.  e.,  the  sound  as  heard  in  the  second  intercostal 
space  on  the  left  side  of  the  sternum.  Lesions  of  the  semilunar 
valves  of  the  pulmonary  artery,  and  of  the  tricuspid  valves,  are  of 
extremely  infrequent  occurrence.  Exaggerated  intensity  of  the 
pulmonary  second  sound,  therefore,  is  highly  significant  of  hyper- 
trophy of  this  ventricle.  This  effect  is  especially  marked  if,  in 
conjunction  with  increased  power  of  the  ventricular  contraction, 
there  exists  congestion  of  the  pulmonary  vessels  involving  obstruc- 
tion to  the  free  passage  of  blood  through  the  lungs.  The  resistance 
which  the  column  of  blood  propelled  into  the  pulmonary  artery 
meets  with,  induces  a  greater  dilation  of  this  artery  during  the 
ventricular  systole,  and,  consequently,  a  stronger  recoil  after  the 
systole,  giving  rise  to  a  louder  pulmonary  second  sound.  Pulmo- 
nary congestion,  often  due  to  mitral  contraction  or  regurgitation, 
generally  co-exists  with  hypertrophy  of  the  right  ventricle,  and 
stands  to  the  latter  in  the  relation  of  causation.  In  estimating  the 
amount  of  exaggerated  intensity  of  the  pulmonary  second  sound, 
it  is  to  be  compared  with  the  aortic  second  sound  in  the  same 
intercostal  space  on  the  right  side  of  the  sternum.  In  making  this 
comparison,  it  is  to  be  borne  in  mind  that  lesions  affecting  the 
mitral  orifice  (contraction,  or  regurgitation,  or  both),  which  are 


0 

QQ  ENLARGEMENT    OF    THE    HEART. 

often  associated  with  hypertrophy  of  the  right  ventricle,  involve 
diminished  intensity  of  the  aortic  sound  by  lessening  the  amount 
of  blood  propelled  by  the  contraction  of  the  left  ventricle  into  the 
aorta.  Under  these  circumstances,  the  pulmonary  second  sound 
may  be  more  intense  than  the  aortic,  when  its  actual  intensity  is 
not  augmented.  Exaggeration  of  the  pulmonary  second  sound 
occurring  in  connection  with  the  mitral  lesions  just  named,  will  be 
again  noticed  in  treating  of  these  lesions.  It  is  also  to  be  borne  in 
mind  that  in  mere  functional  excitement  of  the  heart,  both  the 
pulmonary  and  aortic  second  sound  acquire  an  abnormal  intensity. 
Under  these  circumstances,  the  second  sound,  in  both  situations,  is 
alike  exaggerated.  Abnormal  increase  of  the  intensity  of  the  sound 
emanating  from  either  the  aorta  or  pulmonary  artery,  is  more  signi- 
ficant of  hypertrophy  than  when  the  sound  from  both  of  these 
sources  is  alike  augmented.  But  with  respect  to  the  second,  as 
well  as  the  first  sound,  abnormal  increase  of  intensity  is  to  be 
considered  as  a  sign  of  hjq^ertrophy  only  when  other  physical  signs 
of  enlargement  of  the  heart  are  at  the  same  time  present.  Another 
point  is  not  to  be  lost  sight  of,  viz  :  In  the  progress  of  hypertrophy, 
a  period  arrives  when  the  muscular  power  of  the  heart  becomes 
abnormally  weak,  notwithstanding  the  increased  thickness  of  the 
muscular  walls.  When  this  period  arrives,  the  heart-sounds  are 
feeble  in  proportion  to  the  weakness  of  the  ventricular  contractions. 
Enlargement  of  the  heart  gives  rise  to  certain  abnormal  changes 
as  regards  the  respiratory  murmur  and  vocal  resonance  within  the 
prsecordia,  which  possess  some  importance  as  physical  signs.  In 
health,  the  respiratory  murmur  may,  or  may  not  be  perceived 
within  the  superficial  cardiac  region  during  tranquil  breathing ; 
but  it  is  generally  heard  everywhere  within  the  priecordia  when  the 
breathing  is  forced.  In  cases  of  enlargement,  however,  in  which 
the  area  of  the  superficial  cardiac  region  is  increased,  not  only  is 
the  murmur  in  tranquil  breathing  inappreciable,  but  it  may  not  be 
discoverable  although  the  breathing  be  forced.  This  is  corrobora- 
tive of  the  more  reliable  evidence  of  enlargement  afforded  by  per- 
cussion and  palpation.  The  vocal  resonance,  in  health,  when  more 
or  less  marked  over  the  left  side  of  the  chest,  is  either  extinct  or 
notably  diminished  within  the  prascordial  region.  The  boundaries 
of  the  heart  may  often  be  as  accurately  defined  by  auscultating  the 
voice  as  by  percussion;  and,  in  conjunction  with  the  latter  method, 
the  former  may  be  resorted  to  in  determining  the  augmented  space 
which  the  heart  occupies  in  cases  of  enlargement. 


SIGXS  BY  INSPECTION.  67 

4.  Enlargement  of  the  prBecordia  and  abnormal  movements,  as  deter- 
mined by  inspection. 

In  healthy  persons,  free  from  spinal  curvature  and  obvious  de- 
formity of  the  chest,  the  prtecordial  region  and  the  corresponding 
section  on  the  right  side  do  not  present  any  marked  deviation  from 
symmetry.  On  close  comparison  with  the  eye,  frequently  a  slight 
disparity  is  perceived,  one  side  projecting  a  little  more  than  the 
other.  Of  the  instances,  according  to  my  observations,  in  which 
this  disparity  is  perceptible,  the  right  and  the  left  side  are  found  to 
project  in  an  equal  proportion.  Of  twenty-five  examinations  of 
different  persons  in  health,  with  well  formed  chests,  and  no  spinal 
curvature  ;  in  seven,  no  disparity  was  observable ;  and  in  an  equal 
number,  viz.,  in  nine,  the  right  and  the  left  side,  respectively,  were 
found  to  be  slightly  more  prominent.  Three  of  these  persons  were 
left  handed.  In  one  of  these  three  persons,  the  right  side  was 
more  prominent ;  in  another,  the  left  side,  and  in  one  there  was  no 
disparity.' 

Abnormal  prominence  of  the  preecordial  region  occurs  in  certain 
cases  of  enlargement  of  the  heart.  The  prominence  is  considerable 
in  some  cases,  when  the  heart  is  enlarged  in  early  life.  In  a  mod- 
erate amount,  it  is  not  uncommon  in  cases  in  which  the  affection  is 
developed  after  adult  age.  Praecordial  prominence,  due  to  the 
accumulation  of  liquid  within  the  pericardial  sac,  in  cases  of  peri- 
carditis, may  generally  be  distinguished  from  that  due  to  enlarge- 
ment of  the  heart,  by  characters  determinable  by  inspection, 
although  the  differential  signs  obtained  by  other  methods  of  ex- 
ploration are  more  strongly  marked.  The  shape  of  the  praecordial 
projection  is  not  the  same  in  enlargement  of  the  heart  as  in  peri- 
carditis with  effusion.  In  the  latter  it  extends  more  in  a  vertical 
than  in  a  transverse  direction.  In  the  former,  the  arching  is  wider, 
and  does  not  extend  much,  if  at  all,  above  the  normal  situation  of 

'  M.  Woillez  found,  of  197  subjects  in  good  health,  and  without  spinal  curva- 
ture, that  in  47  only  was  the  symmetry  absolutely  perfect.  A  projection  of  the 
left  side,  in  front,  either  at,  or  above,  or  below  the  nipple,  existed  in  the  proportion 
of  26  per  cent.  An  anterior  projection  of  the  right  side  existed  in  only  two  in- 
stances. The  proportion  of  instances  in  which  deviation  from  absolute  symmetry 
existed  in  my  comparatively  few  examinations,  agree  very  nearly  with  those  of  M. 
Woillez.  The  proportion  of  instances  in  which  prominence  of  the  left  side  was 
noted  is  larger  in  my  examinations,  and  the  relative  number  of  instances  in  which 
prominence  of  the  right  side  was  observed,  is  still  greater. 


68  ENLARGEMENT    OF    THE    HEART, 

the  base  of  tlie  heart.  Priecordial  prominence  due  to  enlargement, 
if  it  exist  in  a  notable  degree,  denotes  both  hypertrophy  and  dila- 
tation, because  it  is  in  this  species  of  enlargement  that  the  heart 
attains  to  a  large  size.  The  projection  is  very  rarely,  if  ever,  so 
great  as  in  certain  cases  of  chronic  pericarditis.  The  intercostal 
depressions  are  not  so  uniformly  abolished.  Bulging  of  the  inter- 
costal spaces,  which  may  result  from  pericardial  effusion,  never 
occurs  in  cases  of  enlargement.  Widening  of  the  intercostal  spaces 
does  not  take  place  to  the  same  extent  in  cases  of  the  latter  as  of 
the  former.  In  enlargement,  the  apex-beat  is  generally  seen  and 
felt,  while  in  pericarditis  it  is  often  suppressed ;  and  if  appreciable 
in  the  latter  affection,  it  is  raised  above  its  normal  position,  while 
in  the  former  it  is  often  lowered  and  carried  to  the  left.  Other 
points  of  distinction  will  be  noticed  in  treating  of  pericarditis.  It 
may  be  added  here  that  the  prominence  dependent  on  enlargement 
is  permanent  and  unchangeable,  while  that  due  to  pericardial  effu- 
sion is  sometimes  developed  under  the  eyes  of  the  practitioner,  and, 
after  variations  at  different  times,  may  finally  disappear  and  be 
followed  by  depression. 

Movements  of  impulsion  and  retraction  referable  to  the  heart  in 
cases  of  enlargement,  which  have  been  considered  in  connection 
with  palpation,  are,  in  general,  appreciated  by  the  eye  as  well  as 
by  the  touch.  Retractive  movements  may  be  ascertained  by  in- 
spection when  they  are  not  perceived  by  palpation.  The  retraction 
of  the  apex-beat  is  sometimes  plainly  seen,  when  an  impulse  can- 
not be  felt.  The  alternate  movements  in  different  intercostal 
spaces,  which  were  described  as  determined  by  palpation,  are  best 
ascertained  by  inspection.  The  applicability  of  this  method  of 
exploration  to  the  study  of  the  movements  communicated  by  the 
heart  to  the  thoracic  walls,  is  to  be  borne  in  mind,  but  it  is  need- 
less to  repeat  in  this  connection  the  account  of  these  movements, 
which  has  been  already  given. 

5.  Increased  size  of  the  chest  as  determined  by  mensuration. 

The  value  of  mensuration  in  cases  of  enlargement  of  the  heart, 
consists  in  its  giving  exactitude  to  certain  of  the  signs  obtained  by 
inspection.  It  is  not  essential  to  the  development  of  data  for  diag- 
nosis. 

As  regards  measurements  of  the  healthy  chest,  with  reference  to 
the  prcecordia,  the  following  are  the  conclusions  deduced  from 


SIGNS  BY  MENSURATION.  69 

twenty-five  examinations  in  which  the  circumference  was  measured 
with  graduated  inehistic  tape,  and  the  diametrical  distance  by 
means  of  callipers.  Equality  of  the  two  sides  of  the  chest,  and  a 
greater  size  of  the  left  side,  as  regards  circumference  and  antero- 
posterior diameter,  do  not  alone  constitute  evidence  of  cardiac  or 
other  intra-thoracic  disease.  This  statement  holds  good  within 
certain  limits ;  in  other  words,  greater  size  of  the  left  than  of  the 
right  side  beyond  half  an  inch,  either  by  diametrical  or  circular 
measurement,  points  to  the  existence  of  disease.  Diametrical 
measurement  gives  a  larger  number  of  instances  in  which  the  two 
sides  are  equal,  than  circular  mfeasurement,  the  ratio  being  six  to 
eleven.  The  right  side  was  greater  in  eleven  instances  as  measured 
by  the  tape,  and  in  seven  as  measured  by  callipers,  A  greater  size 
of  the  left  side  existed  in  an  equal  number  of  instances  as  deter- 
mined by  the  tape  and  callipers,  viz.,  in  five.  In  all  of  sixteen 
cases  in  which  diametrical  measurement  showed  greater  size  of 
either  the  right  or  left  side,  the  same  results  had  been  previously 
obtained  by  inspection,  with  a  single  exception. 

Thus,  in  confirming  and  giving  greater  exactitude  to  the  results 
of  inspection,  as  respects  the  size  of  the  chest  in  cases  of  cardiac 
disease,  diametrical  is  to  be  preferred  to  circular  measurement. 

The  antero-posterior  diameter  of  the  chest  at  the  prsecordia  is 
increased  in  certain  cases  of  enlargement  of  the  heart.  In  deter- 
mining that  it  is  due  to  cardiac  disease,  abnormal  conditions  refer- 
able to  the  lungs  or  pleura,  increasing  the  size  of  the  chest,  are  to 
be  excluded  by  the  absence  of  the  signs  denoting  their  existence  ; 
and  the  abnormal  increase  of  the  diametrical  dimension  of  the  left 
side  is  referred  to  an  abnormal  condition  of  the  heart,  not  alone  by 
the  exclusion  of  diseases  affecting  other  intra-thoracic  structures, 
but  by  concomitant  signs  of  cardiac  enlargement.  The  advantage 
of  mensuration  as  already  stated,  is  mainly  in  corroborating  the 
evidence  afforded  by  the  eye,  and  in  enabling  the  physician  to  de- 
termine with  greater  precision  the  amount  of  disparity  between  the 
two  sides.  In  recording  cases,  it  is  more  satisfactory  to  note  the 
results  of  a  comparison  of  the  two  sides  in  figures  than  to  express 
them  in  terms  which  are  somewhat  indefinite;  such  as  slight, 
moderate,  great,  etc.  With  reference  simply  to  diagnosis  in  indi- 
vidual cases,  inspection  suffices  without  resorting  to  measurement. 

The  diagnosis  in  cases  of  enlargement  of  the  heart  and  hyper- 
trophy must  rest  on  the  physical   signs.     The  symptoms  which 


70  EXLARGEilEXT    OF    THE    HEART. 

have  been  mentioned  (page  33)  may  point  to  these  lesions,  and 
afford  corroborative  evidence  of  their  existence,  but  they  are  not 
adequate  to  lead  to  positive  conclusions.  So  far  as  concerns  en- 
largement, it  is  determinable  with  great  ease  and  precision  b}' 
means  of  physical  signs  in  the  vast  majority  of  cases.  To  deter- 
mine Avhether  hypertrophy  or  dilatation  predominate  is  more 
difficult,  but  in  most  instances  it  is  practicable  with  due  knowledge 
and  care.  As  res-ards  these  two  forms  of  enlaro;ement.  the  differ- 
ential  diagnosis  will  be  considered  under  the  head  of  enlargement 
by  dilatation  in  an  after  part  of  this  chapter.  The  signs  involved 
in  the  diagnosis  of  enlargement  and  hypertrophy  are  fewer  and 
more  simple  than  would  appear  from  the  space  devoted  to  the 
subject  in  this  chapter.  The  subject  would  here  require  compara- 
tively brief  consideration  had  it  not  been  requisite,  in  this  connec- 
tion, to  introduce  accounts  of  the  phenomena  obtained  by  physical 
exploration  in  health,  as  the  point  of  departure  for  studying  the 
phenomena  of  disease  relating  not  alone  to  the  diagnosis  of  the 
affections  treated  of  in  this  chapter,  but  to  those  Avhich  are  to  be 
subsequently  considered.  The  greater  part  of  the  present  section 
has  been  occupied  with  facts  which  belong  to  physiology  rather 
than  pathology.  Having  been  here  introduced,  it  will  only  be 
necessary  to  allude  to  them  hereafter  in  treating  of  subjects  as 
preliminary  to  which  they  are  equally  important.  For  the  conve- 
nience of  the  reader,  a  recapitulation  of  the  physical  signs  of 
enlargement  and  of  hypertrophy  is  given  in  the  summaries  which 
follow. 

SUMMARY  OF  THE  PHYSICAL  SIGN'S  OF  EXLAKGEMEXT  OF  THE  HEART. 

1.  Percussion. — The  area  of  the  superficial  cardiac  region  ex- 
tended beyond  the  range  of  healthy  variation,  especially  in  width. 
The  degree  of  dulness  within  this  area  greater  than  in  health,  and 
the  sense  of  resistance  more  marked.  The  limits  of  the  deep 
cardiac  region,  in  other  words,  the  boundaries  of  the  heart,  gene- 
rally defined  by  careful  percussion,  the  dimensions  of  the  space 
which  the  heart  occupies  being  thus  ascertained  with  precision,  and 
the  form  of  the  organ  delineated  on  the  chest.  Enlargement  of  the 
right  or  left  auricle  sometimes  determined  by  the  extent  of  the  area 
of  dulness  at  tlie  base  of  the  heart  on  the  right  or  left  side  of  the 
sternum. 


SUMMARY  OF  SIGNS  OF  EXLAEGEMENT.  71 

2.  Palpation. — The  apex-beat  removed  to  the  left  of  its  normal 
position,  and  often  lowered.  The  area  within  which  the  apex-beat 
is  felt,  extended  bejond  the  range  of  health.  Abnormal  impulses 
felt  in  two,  three,  and  sometimes  even  four  intercostal  spaces ;  the 
additional  impulses  either  synchronous  or  alternating  with  the 
apex-beat,  in  some  instances  referable  to  the  auricles,  although  due 
to  the  ventricular  systole ;  and,  when  felt  in  the  epigastrium,  due 
to  the  action  of  the  right  ventricle. 

3.  AuscuUation. — The  respiratory  murmur  not  appreciable  within 
the  superficial  cardiac  region  in  tranquil  breathing,  and  sometimes 
wanting  when  the  breathing  is  forced ;  feeble  over  a  larger  area 
within  the  pr^ecordia  than  in  health.  The  boundaries  of  the  heart 
defined  by  abrupt  cessation  or  notable  diminution  of  vocal  reso- 
nance, and  the  augmented  space  which  the  organ  occupies,  in  this 
way  determinable  in  corroboration  of  the  evidence  afforded  by 
percussion. 

4.  Inspection. — Abnormal  projection  of  the  prascordial  region  in 
some  cases;  the  projection  considerable  if  the  enlargement  take 
place  in  early  life.  The  movements  of  impulsion  determined, 
which  are  also  ascertained  by  palpation ;  movements  sometimes 
seen  which  are  not  perceptible  to  the  touch,  especially  movements 
which  commence  by  depression  with  the  systole  of  the  ventricles. 
Alternate  movements  of  intercostal  spaces  often  apparent  to  the  eye, 
which  are  imperfectly  ascertained  by  palpation. 

5.  Mensuration. — Prominence  of  the  pri^cordia  greater  than  the 
corresponding  portion  of  the  chest  on  the  right  side ;  in  some  cases 
apparent  on  inspection,  but  determined  with  precision  by  diametri- 
cal measurement.  Mensuration  also  employed  in  determining  with 
accuracy  the  dimensions  of  the  superficial  and  deep  cardiac  regions, 
the  position  of  the  apex-beat  relatively  to  the  nipple,  the  median 
line,  etc. 

SUMMARY  OF  PHYSICAL  SIGNS  DISTINCTIVE  OF  ENLARGEMENT  BY  HYPERTROPHY. 

1.  Palpation. — Abnormal  force  of  the  apex-beat,  denoting  not 
merely  excited  action  of  the  heart,  but  augmented  power  of  the 
systole  of  the  left  ventricle,  the  impulsion  prolonged,  sluggish,  and 
strong.     A  strong  impulse  in  the  epigastrium  in  cases  of  hyper- 


72  ENLARGEMENT    OF    THE    HEART, 

trophy  of  the  right  ventricle ;  the  impulsions  sometimes  commu- 
nicated to  the  lower  part  of  the  sternum,  and  extending  more  or 
less  over  the  site  of  the  liver.  A  strong,  heaving  movement  of  the 
ribs  or  the  entire  prcecordia,  in  distinction  from  the  shock,  more  or 
less  violent,  due  merely  to  augmented  functional  activity  of  the 
ventricles. 

2.  Auscultation. — Exaggeration  of  the  aortic  second  sound,  and 
especially  of  the  element  of  impulsion  of  the  first  sound,  in  hyper- 
trophy of  the  left  ventricle,  rendering  the  first  sound  dull  and  pro- 
longed, as  well  as  abnormally  intense.  Exaggerated  intensity  of 
the  pulmonary  second  sound,  in  hypertrophy  of  the  right  ventricle, 
especially  if  associated  with  obstruction  to  the  pulmonary  circula- 
tion. Augmentation  of  the  tricuspid  valvular  element  of  the  first 
sound  in  some  cases  of  hypertrophy  of  the  right  ventricle. 


Treatment  op  Hypertrophy, 

False  notions  of  the  pathology  of  hypertrophy  have  hitherto  led 
to  erroneous  principles  of  treatment,  which  govern,  still,  the  prac- 
tice of  very  many,  if  not  most  physicians.  The  object  has  been  to 
devise  the  most  effective  means  of  diminishing  the  state  of  hyper- 
trophy, i.  e.,  of  reducing  the  size  of  the  ventricular  walls,  and,  if 
this  be  not  practicable,  of  preventing,  if  possible,  progressive  in- 
crease of  the  muscular  tissue.  For  this  end,  some  years  age,  copious 
and  repeated  abstractions  of  blood  were  employed,  in  conjunction 
with  low  diet,  after  the  plan  of  "Valsalva  and  Albertini,  Italian 
physicians.  This  method  was  found  to  be  pernicious,  but,  instead 
of  being  discarded,  the  same  plan,  not  carried  to  the  same  extent, 
was  recomm.ended  by  Hope,  Bouillaud,  and  others,  and  has  been 
generally  pursued  up  to  the  present  time.  A  better  understanding 
of  the  pathological  relations  of  hypertrophy  leads  to  the  conclusion 
that  therapeutical  measures  designed  to  diminish  or  prevent  it,  are 
likely  to  do  harm  in  so  far  as  they  have  efficiency  in  promoting 
these  ends.  Considered  in  connection  with  the  antecedent  morbid 
conditions  which  give  rise  to  it,  conditions  involving  impediment 
to  the  circulation,  hypertrophy,  so  far  from  being  an  evil,  is  an  im- 
portant provision  against  the  dangers  incident  to  accumulation  of 
blood  within  the  cavities  of  the  heart,  and  against  the  evils  of  dila- 
tation, the  latter  being  much  the  more  serious  of  the  two  forms  of 


TREATMENT  OF  HYPERTROPHY.  73 

enlargement.  In  the  great  majority  of  cases,  enlargement  of  the 
heart  is  the  result  of  valvular  lesions.  These  lesions  often  exist 
for  a  long  time  before  they  give  rise  to  symptoms  which  lead  the 
patient  to  suppose  that  he  is  affected  with  disease.  When  cases 
first  come  under  the  notice  of  the  practitioner,  it  is  evident  that  the 
enlargement  has  been  going  on  for  months  or  even  years.  The 
amount  of  enlargement,  when  the  chest  is  for  the  first  time  examined, 
shows  that  it  is  not  of  recent  production.  We  have  seen  that,  as 
regards  hypertrophy  and  dilatation,  which  are  almost  always  com- 
bined, the  former,  as  a  rule,  takes  precedence  in  time.  The  hyper- 
trophy, in  short,  compensates,  during  a  greater  or  less  period,  for 
the  disturbance  of  the  circulation  caused  by  th6  valvular  lesions ; 
and  so  long  as  the  enlargement  consists  of  this  compensating  in- 
crease of  muscular  structure,  and  consequently  of  muscular  power, 
the  patient  experiences  little  or  no  inconvenience,  provided  nothing 
occurs,  like  anemia,  for  example,  to  weaken  the  force  of  the  heart's 
action.  It  is  when  the  hypertrophy  has  reached  the  limit  of  com- 
pensation, and  dilatation  has  followed,  that  serious  inconveniences, 
referable  to  the  heart  and  circulation,  begin  to  be  felt.  With  this 
general  view  of  the  pathological  character  of  hypertrophy,  the  in- 
dications for  treatment  may  be  embraced  in  three  classes,  viz  :  1.  To 
prevent  or  limit,  as  far  as  practicable,  impediment  to  the  circulation 
dependent  on  valvular  lesions  or  other  conditions,  and  giving  rise 
to  hypertrophy ;  2.  To  obviate,  as  far  as  possible,  weakness  of  the 
heart,  and  a  tendency  to  dilatation  ;  3.  To  quiet  undue  excitement 
and  irregular  action  of  the  heart. 

The  antecedent  pathological  conditions  giving  rise  to  cardiac 
enlargement,  viz.,  valvular  lesions,  pulmonary  emphysema,  etc.',  are 
not  of  a  nature  to  admit  of  removal.  The  physician,  however,  can 
do  something  towards  preventing  or  limiting  the  impediment  to 
the  circulation,  which  is  the  immediate  effect  of  these  conditions, 
and  which  is  the  intervening  cause  of  enlargement.  This  indication 
is  fulfilled  by  avoiding  extrinsic  causes  which  excite  unduly  the 
action  of  the  heart,  by  measures  designed  to  equalize  the  circulation, 
and  by  the  judicious  employment  in  some  cases  of  bloodletting  and 
other  means  of  depletion.  Excessive  muscular  exercise  is  objec- 
tionable, but,  as  will  be  seen  presently,  within  certain  limits  it  is 
not  to  be  prohibited,  but  enjoined.  Excesses  in  eating  and  in  the 
use  of  stimulating  drinks  are  to  be  avoided.  ]\rental  excitement 
belongs  in  the  same  category.  The  circulation  is  equalized  by 
securing,  as  far  as  may  be,  for  the  different,  and  especially  the 


74  ENLARGEMEXT    OF    THE    HEART. 

remote  parts  of  the  body  a  proper  proportion  of  blood,  thus  pre- 
venting its  undue  accumulation  within  the  cavities  of  the  heart. 
For  this  end,  the  surface  of  the  body  should  be  guarded  against  the 
influence  of  cold,  and  revulsive  measures,  such  as  warm  and  stimu- 
lating pediluvia,  frequently  resorted  to  if  the  circulation  in  the 
extremities  be  sluggish.  Constipation,  if  it  exist,  claims  appropriate 
remedies.  Bloodletting  is  permissible  when  there  exists  over- 
repletion  of  the  general  vascular  system,  the  object  being,  by 
lessening  the  mass  of  blood,  to  facilitate  its  circulation.  This 
object  should  be  clearly  understood.  It  is  easy  to  understand  that 
if  the  vessels  are  abnormally  full  of  blood,  an  irremediable  impedi- 
ment to  the  circulation  is  likely  to  occasion  greater  accumulation 
in  the  heart  and  its  cavities  than  when  the  mass  of  blood  to  be 
circulated  does  not  exceed  the  normal  amount.  The  existence  of 
plethora  furnishes  the  indication  for  bloodletting,  and  the  removal 
of  this  state  constitutes  the  limit  to  which  it  may  with  propriety  be 
carried.''  Carried  beyond  this  limit,  the  detraction  of  blood  can 
hardly  fail  to  be  pernicious.  It  is  to  be  borne  in  mind  that  blood- 
letting is  not  to  be  practised  because  hypertrophy  exists,  but 
because  over-repletion  of  the  vascular  system,  added  to  an  existing 
permanent  impediment  to  the  circulation,  increases  the  necessity,  as 
it  were,  for  the  production  of  hypertrophy.  Injudiciously  prac- 
tised, bloodletting  is  injurious  in  proportion  as  it  impoverishes  the 
blood  and  weakens  the  muscular  power  of  the  heart.  Eesorted  to 
with  reference  to  the  object  just  stated,  it  is  indicated  in  only  a 
certain  proportion  of  cases,  and  the  abstraction  of  a  large  quantity 
of  blood  is  very  rarely,  if  ever,  called  for.  The  end  for  which 
bloodletting  is  employed  may  generally  be  fulfilled  by  other 
methods  of  depletion  which  involve  less  risk  of  doing  harm.  The 
use  of  saline  laxatives  and  diuretics,  conjoined  with  a  somewhat 
restricted  diet,  and,  more  especially,  with  restriction  in  the  quantity 
of  fluid  ingesta,  will,  in  most  instances,  accomplish  the  object. 
These  means  are  to  be  preferred  on  account  of  their  being  free 
from  the  evils  attending  the  spoliative  effects  of  bloodletting  when 
employed  injudiciously. 

The  inconveniences  arising  from  hypertrophy  are  aggravated  by 

'  It  is  assumed  tliat  the  state  of  plethora,  i.  e.,  abnormal  augmentation  of  the 
mass  of  blood,  may  exist,  and  also  that  when  the  mass  of  blood  is  diminished  by 
bloodletting  or  other  means,  the  vessels  are  not  immediately  refilled.  The  assump- 
tion of  these  points,  in  opposition  to  the  speculative  views  of  some,  is  believed  by 
the  author  to  be  iu  accordance  with  clinical  observation. 


TEEATMENT  OF  HYPERTEOPHY.  75 

weakness  of  the  heart.  All  observers  have  noticed  the  evils  of 
coexistiug  antemia.  Impoverishment  of  the  blood  renders  the 
heart  irritable,  easily  excited  into  violent  and  irregular  activit}', 
while  its  power  of  action  is  impaired.  Alarming  symptoms  are 
sometimes  induced  under  these  circumstances,  which  are  so  entirely 
relieved  by  restoring  the  blood  to  its  normal  condition  that  patients 
imagine  themselves  completely  cured.  A  patient,  rendered  highly 
ancemic  by  lactation,  presented  dyspnoea,  palpitation,  and  oedema 
to  such  an  extent  that  her  condition  seemed  quite  hopeless,  but 
after  weaning,  the  use  of  tonics,  etc.,  she  recovered  apparently 
perfect  health,  so  that,  except  for  the  physical  signs  of  cardiac 
disease,  the  cure  would  have  been  considered  complete.  Two 
years  afterwards  she  had  apoplexy  followed  by  hemiplegia,  which 
terminated  fatally.  The  combination  of  anaemia  and  enlargement 
of  the  heart  is  to  be  prevented,  if  possible ;  and,  if  it  exist,  the 
anaemia,  if  possible,  is  to  be  removed  by  appropriate  measures  of 
medication,  diet,  and  regimen.  Irrespective  of  this  condition  of 
the  blood,  all  agencies  which  tend  to  weaken  unduly  the  force  of 
the  ventricular  contractions  are  contra-indicated.  In  proportion  to 
the  weakness  of  the  heart  will  be  the  tendency  to  dilatation  rather 
than  to  hypertrophy.  The  latter  is  to  be  promoted,  if  this  be 
necessary  to  prevent  the  former.  So  long  as  hypertroph}'-  pre- 
dominates, the  patient  is  comparatively  safe.  The  inconveniences 
and  dangers  are  greatly  increased  in  proportion  as  dilatation  suc- 
ceeds hypertrophy.  It  is  an  important  object  of  treatment,  there- 
fore, to  obviate  or  retard  the  tendency  to  dilatation.  With  reference 
to  this  object,  the  diet  should  be  nutritious — a  substantial,  solid 
diet,  adapted  to  the  formation  of  blood,  rich  in  quality,  but  not  in 
excess  as  regards  quantity.  Muscular  exercise  within  certain 
limits  is  to  be  encouraged  rather  than  repressed.  In  cases  of 
cardiac  disease  attended  with  enlargement,  I  have  been  repeatedly 
struck  with  the  fact  that  persons  engaged  in  pursuits  requiring 
considerable  ph3^sical  exertions,  laborers,  mechanics,  or  active  men 
of  business,  continue  to  discharge  their  duties  for  a  long  time 
without  much  inconvenience,  but  fail  rapidly  so  soon  as  they  dis- 
continue their  occupations.  I  am  convinced  that  a  certain  amount 
of  exercise  is  not  only  allowable,  but  positively  beneficial  by  pro- 
moting the  heart's  vigor  and  retarding  the  passage  from  predomi- 
nant hypertrophy  to  predominant  dilatation.  It  will  doubtless 
seem  at  first  strange  to  many  readers  that  exercise  is  recommended 
in  cases  of  hypertrophy,  but,  while  violent  exertions,  which  excite 


76  ENLARGEMENT    OF    THE    HEART. 

unduly  the  action  of  the  heart,  are  to  be  avoided,  I  am  satisfied 
that  moderate  and  even  considerable  muscular  activity  conduces  to 
the  "welfare  of  the  patient. 

At  the  time  of  writing  I  can  call  to  mind  a  number  of  persons 
affected  with  hypertrophy  complicated  with  valvular  lesions,  who, 
engaged  in  active  occupations,  and  pursuing  no  medical  treatment, 
would  be  amazed  were  they  fully  aware  of  their  pathological  con- 
dition. I  cannot  but  think  that  were  the  nature  and  extent  of  the 
disease  clearly  explained  to  these  persons,  and  great  quietude 
enjoined,  their  chances  for  tolerable  health  for  a  considerable 
period  would  be  materially  impaired.  Still  less  encouraging  would 
be  the  prospect  were  they  subjected  to  a  course  of  diet  and  medica- 
tion tending  to  impoverish  the  blood,  reduce  the  vital  forces,  and 
weaken  the  power  of  the  heart.  I  cannot  avoid  the  reflection  that 
I  have  witnessed  the  injury  inflicted  by  this  course  of  management 
in  not  a  few  cases. 

In  cases  of  complicated  hypertrophy,  the  heart  is  liable  to  be 
unduly  excited,  and  irregular  action  take  place,  even  when  extrinsic 
causes  are,  as  much  as  possible,  avoided.  In  other  words,  func- 
tional disorder,  or  palpitation,  may  be  superadded  to  the  organic 
affections.  This  is  not  only  a  source  of  inconvenience,  but  there 
is  reason  to  believe  that  the  effect  is  unfavorable  as  regards  the 
permanent  condition  of  the  heart.  To  quiet  undue  excitement  and 
irregular  action  of  the  heart,  is  therefore  an  object  of  treatment. 
Certain  remedies  may  be  employed  with  advantage  for  this  object. 
Digitalis  is  a  valuable  remedy,  frequently  exerting  a  sedative  effect 
upon  the  heart,  without  lessening  the  power  of  its  action.  Under 
its  judicious  use,  the  ventricular  contractions  often  become  less 
frequent,  more  regular,  and  apparently  more  complete.  Care  is 
to  be  taken  not  to  give  it  in  doses  sufficient  to  reduce  the  pulse 
much  below  its  normal  frequency,  and  with  due  care  it  may  be  con- 
tinued for  some  time  without  risk  of  unpleasant  consequences. 
Bouillaud  claims  that  its  endermic  application,  blistering  a  small 
space,  and  sprinkling  daily  several  grains  on  the  blistered  surface 
denuded  of  its  cuticle,  possesses  great  advantages.  Others,  how- 
ever, have  not  observed  that  the  beneficial  effects  are  more  marked 
when  this  method  is  employed,  than  when  it  is  administered  in- 
ternally. It  is  possible  that  the  same  effects  may  be  obtained  from 
the  use  of  the  veratrum  viride,  introduced  by  Dr.  Norwood. 
Aconite  is  highly  extolled  by  Dr.  Walshe.  He  gives  this  the  pre- 
ference over  any  other  remedy  in  meeting  the  indication  under 


ENLARGEMENT  BY  DILATATION.  77 

consideration.  Belladonna  is  useful  in  some  cases.  A  belladonna 
plaster,  worn  over  the  prascordia,  lias  seemed  to  me  to  exert  a 
decided  effect  in  tranquillizing  the  heart.  The  sedative  effect  of 
hydrocyanic  acid  is  useful  in  some  cases. 

In  these  remarks  on  the  treatment  of  hypertrophy,  I  have  not 
discussed  the  feasibility  of  diminishing  the  abnormal  growth  of  the 
muscular  walls  of  the  heart,  a  subject  concerning  which  different 
writers  have  held  opposite  opinions.  The  views  of  the  pathological 
character  of  hypertrophy  which  have  been  presented,  divest  this 
subject  of  the  practical  importance  which  has  heretofore  been  at- 
tached to  it. 


ENLARGEMENT   BY   DILATATION, 


Under  this  head  are  embraced,  in  addition  to  the  rare  instances 
of  pure  or  simple  dilatation,  ?'.  e,,  cases  in  which  the  capacity  of  the 
cavities  is  increased,  and  the  walls  attenuated,  all  cases  in  which 
the  relative  amount  of  dilatation  exceeds  that  of  hypertrophy.  Of 
the  two  kinds  of  enlargement,  this  is  by  far  the  most  frequently 
found  after  death  in  the  cases  in  which  organic  disease  of  the  heart 
proves  fatal.  In  the  instances  in  which  the  heart  attains  to  a  very 
large  size,  dilatation  almost  invariably  preponderates.  The  cases 
in  which  the  organ,  from  its  immensely  augmented  bulk,  resembles 
a  bullock's  heart  [cor  hovinum),  are  those  in  which  there  exists  a 
great  amount  of  hypertrophy,  together  with  a  still  larger  amount  of 
dilatation.  The  degree  of  dilatation  varies  greatly  in  different  cases, 
and  the  lesser  amount  of  hj^pertrophy  combined  with  it,  is  also  vari- 
able. The  preponderance  of  the  dilatation,  when  the  heart  is  ex- 
amined after  death,  is  generally  sufficiently  evident  on  inspection. 
The  abnormal  increase  in  the  dimensions  of  the  organ  exceeds  that 
of  the  weight.  The  ventricular  walls  collapse,  and  the  organ,  resting 
on  its  posterior  surface,  is  flattened,  instead  of  preserving  a  globular 
form,  as  when  hypertrophy  predominates.  The  greater  increase  in 
width  than  in  length,  is  marked  in  proportion  to  the  preponderance 
of  dilatation.  Owing  to  this,  the  organ  becomes  wedge-shaped, 
and  sometimes  presents  nearly  a  square  form. 

The  pathological  process  involved  in  dilatation  is  quite  different 
from  that  which  occasions  hypertrophy.     In  the  latter  instance,  the 


78  EXLARGEilEXT    OF    THE    HEART. 

process  is  vital,  in  the  former,  mechanical.  Hypertrophy  is  a  con- 
sequence of  over-nutrition ;  dilatation  is  the  result  of  the  3nelcling 
of  the  walls  of  the  heart  to  a  distending  force.  The  condition, 
however,  which  stands  immediately  in  a  causative  relation  to  both 
processes  is  the  same,  viz.,  undue  accumulation  of  blood  within  the 
cavities  of  the  heart;  hence  it  is  that  both  processes  take  place 
either  conjointly  or  in  succession,  and  that  hypertrophy  and  dila- 
tation are  almost  invariably  associated.  Dilatation,  thus,  not  less 
than  hypertrophy,  depends  on  antecedent  affections  which  occasion 
impediment  to  the  circulation  through  the  vessels  or  the  orifices  of 
the  heart,  leading  to  over-accumulation  of  blood  within  the  centres. 
These  antecedent  affections,  with  which  the  dilatation  is  complicated, 
are  the  same  as  in  cases  of  predominant  hypertrophy ;  and  the 
several  compartments  of  the  heart  become  affected  singly  and  in 
succession,  as  in  the  latter  form  of  enlargement.  It  is  not  neces- 
sary, therefore,  in  this  connection,  to  consider  the  dilatation  of 
these  compartments,  respectively,  in  relation  to  the  particular 
lesions  of  the  valves  and  orifices  and  vessels  on  which  dilatation 
and  hypertrophy  alike  depend.  Moreover,  both  dilatation  and 
hypertrophy  of  the  different  divisions  of  the  heart  will  be  referred 
to  hereafter  in  treating  of  valvular  lesions.  It  will  suffice  to  inquire 
into  the  circumstances  which  determine  the  occurrence  of  dilatation 
in  the  place  of,  or,  as  is  generally  the  case,  in  addition  to  hyper- 
trophy.' 

The  first  effect  of  an  undue  accumulation  of  blood  in  the  cavities 
of  the  heart,  continued  for  a  sufficient  period,  is  increased  muscular 
action  and  consequent  hj^pertrophy  in  the  great  majority  of  cases. 
The  hypertrophy  is  more  or  less  progressive,  but  it  has  its  limit. 
The  abnormal  growth  of  the  muscular  tissue  ceases  at  a  certain 
point.  But  the  morbid  conditions  inducing  over-repletion  of  the 
cavities,  still  remain,  impeding  more  and  more  the  circulation. 
The  compensating  increase  of  the  muscular  tissue  no  longer  taking 
place,  the  walls  of  the  cavities  yield  to  the  mechanical  force  of 
distension  and  the  progressive  enlargement  from  this  time  onward 
is  due  to  dilatation.  The  limit  of  hypertrophic  enlargement  varies 
in  different  persons.  If  it  do  not  cease  till  the  muscular  walls 
attain  to  a  great  thickness,  and  life  continue  for  a  long  period 
afterward,  the  dilatation  finally  predominates,  and  the  result  is  an 

'  Of  209  cases  of  dilatation  analyzed  by  Dr.  T.  K.  Chambers  (Decennium  Patho- 
logicum),  in  69  the  valves  were  free  from  disease,  leaving  140  cases  of  complicated 
dilatation. 


EXLARGEMENT  BY  DILATATION.  79 

enormous  enlargement  of  the  heart,  a  cor  bovinum.  But  dilatatioa 
may  commence  after  moderate  or  slight  hypertrophy  has  taken 
place ;  in  other  words,  the  hypertrophy  ceases  after  a  smaller  amount 
of  muscular  growth,  and  dilatation  commences.  Dilatation  may 
even  commence  without  any  previous  hypertroph}-,  and  the  result 
is,  then,  enlargement  with  attenuated  walls,  or  simple  dilatation,  a 
rare  variety  of  cardiac  enlargement.  The  occurrence  of  dilatation 
is  determined  by  the  state  of  the  muscular  walls.  Functional 
debility  of  the  organ,  and,  still  more,  changes  in  the  muscular 
fibres,  prevent  that  vigorous  activity  which  induces  abnormal 
growth,  and  yielding  of  the  walls  takes  place  early  in  proportion 
as  the  vital  power  of  resistance  is  impaired.  Anaemia,  the  feeble- 
ness consequent  on  pericarditis  and  adherent  pericardium,  fatty 
degeneration,  softening,  and  any  changes  which  compromise  the 
muscular  power  of  the  organ,  tend  to  abridge  hypertrophy  and 
favor  dilatation.  The  latter  will  therefore  predominate  in  propor- 
tion as  the  condition  of  the  walls  is  such  that  they  early  and  readily 
yield  to  the  distension  caused  by  the  accumulation  of  blood  within 
the  cavities.  After  this  brief  consideration  of  the  circumstances 
determining  the  occurrence  of  dilatation,  in  addition  to  the  inci- 
dental remarks  already  made  under  the  head  of  enlargement  by 
hypertrophy,  the  reader  will  be  able  to  trace  the  relations  of  dila- 
tation affecting  the  different  cavities  of  the  heart  to  lesions  of  the 
mitral  and  aortic  orifices,  involving  either  obstruction  or  reouroi- 
tation,  or  both ;  and  to  obstructions  affecting  the  pulmonary  and 
systemic  arterial  systems  at  situations  more  or  less  remote  from 
the  heart,  without  a  recapitulation  of  the  account  already  given  in 
connection  with  hypertrophy.  The  inquiry  arises.  Does  not  the 
heart  in  some  instances  become  dilated  in  consequence  of  inherent 
weakness,  no  antecedent  affections  existing  to  occasion  impediment 
to  the  circulation?  It  is  probable  that  this  sometimes  occurs  as  an 
effect  of  fatty  degeneration,  pericardial  adhesions,  atrophy  or  soft- 
ening of  the  muscular  fibres,  etc.  Examples  are  found  of  dilatation 
associated  with  these  structural  changes,  and  without  other  obvious 
sources  of  impediment  to  the  circulation.  These  changes  may  take 
place  subsequent  to  dilatation,  but  it  is  reasonable  to  suppose  that 
in  some  instances  they  precede  and  give  rise  to  it.  Clinical  ob- 
servation, however,  furnishes  no  evidence  that  functional  weakness 
alone  leads  to  dilatation,  irrespective  of  structural  changes  of  the 
walls  of  the  heart,  or  lesions  of  some  kind  which  occasion  impedi- 
ment to  the  circulation.     Dr.  T.  K.  Chambers  has  sugo-ested  that 


so  ein-argement  of  the  heart. 

general  obesity  may  prove  a  cause  of  dilatation,  in  consequence  of 
the  "  increased  area  of  capillaries  through  which,  the  blood  has  to 
be  propelled  in  fat  people.'" 


Symptoms  and  Pathological  Effects  of  Dilatation. 

The  symptoms  due  to  dilatation,  like  those  of  hypertrophy,  are 
generally  so  involved  with  those  incident  to  valvular  or  other  con- 
comitant lesions,  that  it  is  difficult,  if  not  impossible,  to  disconnect 
them  entirely  from  the  latter  in  individual  cases.  The  materials 
for  the  clinical  history  of  simple,  uncomplicated  dilatation  (exclud- 
ing not  only  valvular  lesions  and  obstructive  affections  more  or 
less  removed  from  the  heart,  but  also  diseases  of  the  pericardium 
and  structural  changes  of  the  cardiac  walls),  are  yet  to  be  collected. 
An  approximation,  however,  may  be  made  toward  the  symptoma- 
tology of  this  form  of  enlargement,  by  contrasting  cases  of  com- 
plicated hypertrophy  with  those  of  complicated  dilatation.  In 
proportion  as  dilatation  predominates,  the  power  of  the  heart  is 
impaired.  The  symptoms  distinctive  of  dilatation,  in  fact,  proceed 
from  feebleness  and  incompleteness  of  the  heart's  action.  The 
action  of  the  heart  is  often  irregular,  as  represented  by  irregularity 
of  the  pulse  and  of  the  apex-beats.  Both  are  abnormally  feeble. 
The  pulse  may  be  unequal  as  well  as  irregular,  but  it  is  difficult 
to  say  to  what  extent  this  may  be  owing  to  concomitant  valvular 
affections.  The  patient  experiences  more  or  less  uneasiness  and 
undefinable  distress  referable  to  the  prrecordia,  but  he  is  not  con- 
scious of  that  powerful  action  of  the  heart  which  characterizes 
hypertroph3^  Visible  throbbing  of  the  superficial  arteries  is  not 
perceived.  The  extremities  and  surface  of  the  body  are  cool. 
Lividity  may  be  apparent  on  the  prolabia,  the  tongue,  face,  and 
extremities.  The  veins  may  be  distended.  These  symptoms  are 
more  or  less  marked  in  proportion  as  the  dilatation  affects  the  left 
ventricle.  Dyspnoea  will  be  prominent  in  proportion  as  the  right 
ventricle  is  the  seat  of  dilatation.  The  recumbent  position,  with 
the  head  low,  may  be  insupportable,  and  in  an  advanced  stage,  the 
suffering  from  defective  hoematosis  may  amount  to  orthopnoea. 
Occurring  in  paroxysms,  this  difficulty  of  respiration  constitutes 
the  affection  called  cardiac  asthma.     Exercise,  and  mental  excite- 

'  Bellingliam  on  Diseases  of  the  Heart,  Part  2.     Dublin,  1857,  p.  465. 


SYMPTOMS    OF    DILATATIO'  81 

meut  exasperate  the  symptoms,  particularly  those  referable  to  the 
respiration.  More  or  less  cough  and  expectoration  are  usually 
present.  The  abdominal  viscera,  as  -well  as  the  lungs,  are  in  a 
state  of  passive  congestion.  Owing  to  this  state,  the  liver  is 
often  more  or  less  enlarged  permanently,  and  may  be  found  to 
augment  rapidly  in  size  when,  from  any  cause,  the  circulation  is 
temporarily  embarrassed  in  an  unusual  degree,  resuming  its  former 
dimensions  when  the  paroxysm  ends  and  the  heart  recovers  its 
habitual  strength.'  The  digestive  functions  are  weakened,  but 
nutrition  may  be  sufficiently  active;  patients  do  not  always  emaciate. 
The  urine  is  not  abundant,  and  may  be  found  slightly  albuminous, 
which  is  due  to  renal  congestion  and  not  necessarily  indicative  of 
structural  disease  of  the  kidneys.  Granular  degeneration,  or 
Bright's  disease,  is,  however,  associated,  in  a  certain  proportion  of 
cases,  with  dilatation  as  with  hypertrophy.  Finally,  oedema  occurs, 
first,  manifested  in  the  lower  extremities,  thence  extending  over  the 
body,  and  effusion  into  the  serous  cavities  succeeds,  constituting 
general  dropsy. 

This  is  an  enumeration  of  the  more  important  of  the  symptoms 
belonging  to  cases  of  enlargement  in  which  dilatation  predominates, 
but  it  is  to  be  borne  in  mind  that,  in  general,  valvular  or  other 
lesions  co-exist,  which,  after  inducing  more  or  less  hypertrophy  in 
the  great  majority  of  cases,  have  at  length  led  to  the  superinduction 
of  dilatation ;  and,  under  these  circumstances,  it  is  difficult  to  say  to 
what  extent  the  symptoms  distinctive  of  this  stage  of  the  disease 
may  not  be  due  to  the  causes  of  the  dilatation,  in  other  words,  to 
the  degree  and  duration  of  the  concomitant  lesions.  It  can  hardly 
be  doubted  that  considerable  importance  is  to  be  attached  to  the 
dilatation  in  the  production  of  the  symptomatic  phenomena  which 
have  been  mentioned. 

The  pathological  effects  of  dilatation  are  in  a  great  measure  em- 
braced in  the  foregoing  account  of  the  symptoms.  The  dilatation 
is  the  result  of  weakness  of  the  cardiac  walls,  together  with  an 
accumulation  of  blood  within  the  cavities;  and,  on  the  other  hand, 
it  is  the  cause  of  further  diminution  of  the  power  of  the  heart's 
action,  and  consequent  over-repletion.  It  involves,  therefore,  an 
intrinsic  tendency  to  increase.  The  evils  incident  to  enlargement 
are  mostly  referable  to  dilatation.  Little  or  no  inconvenience  is 
felt  so  long  as  the  heart  is  hypertrophied,  and  the  capacity  of  its 

'  Stokes  on  the  Heart  and  Aorta. 


82  ENLAKGEMENT    OF    THE    HEART. 

cavities  not  increased.  But  in  proportion  as  the  latter  takes  place, 
the  quantity  of  blood  to  be  propelled  from  the  cavities  is  greater, 
and  the  ability  of  the  muscular  walls  to  contract  sufficiently  for  its 
propulsion  is  lessened;  hence,  inadequacy  of  the  motive  power  of 
the  central  organ  to  carry  on  the  circulation.  This  inadequacy 
increases  in  more  than  an  arithmetical  ratio  as  the  dilatation  pro- 
gresses. The  immediate  effect  on  the  vascular  system  is  passive 
congestion,  arising  not  alone  from  the  defective  propelling  power 
of  the  heart,  but  from  the  obstacle  presented  to  the  return  of  blood 
to  this  organ  by  the  accumulation  within  its  cavities.  The  ulterior 
effects  dependent  on  congestion  are,  embarrassment  of  the  functions 
of  the  important  organs  of  the  body,  serous  transudation  or  dropsy, 
and,  occasionally,  hemorrhage.  An  occasional  effect  of  great  dila- 
tation conjoined  with  extreme  feebleness  of  the  heart's  action,  is 
the  formation  of  coagula  within  the  cavities.  There  is  reason  to 
believe  that  in  some  instances  in  which  the  accumulation  is  exces- 
sive, and  the  contraction  of  the  walls  extremely  feeble,  the  blood 
coagulates  during  life,  and  proves  the  immediate  cause  of  a  fatal 
termination.  The  formation  of  coagula  in  the  heart  during  life 
will  receive  distinct  consideration  in  a  subsequent  chapter. 


Physical  Signs  and  Diagnosis  or  Dilatation. 

The  physical  signs  of  enlargement  of  the  heart  have  been  already 
fully  considered.  The  signs  distinctive  of  dilatation  are  now  to  be 
noticed.  The  several  methods  of  exploration  which  furnish  evi- 
dence of  enlargement,  supply  certain  indications  pointing  to  dila- 
tation in  distinction  from  hypertrophy.  The  indications  derived 
from  percussion  relate  to  the  form  of  the  area  of  deep  dulness.  If 
the  boundaries  of  the  heart  are  delineated  on  the  chest  by  careful 
percussion,  the  transverse  dimensions  of  the  area  preponderates 
over  the  vertical,  in  proportion  as  the  dilatation  predominates  over 
hypertrophy.  This  corresponds  to  the  difference  as  regards  the 
form  of  the  heart,  which  has  been  mentioned.  The  outline  which 
the  heart  presents  is  wedge-shaped  or  nearly  square  if  the  dilata- 
tion be  excessive.  Palpation  furnishes  negative  characters  more 
readily  available  and  striking.  The  sluggish,  powerful  apex-beat 
of  hypertrophy  is  wanting ;  also  the  elevation  of  the  ribs  and  the 
heaving  of  the  prsecordia.  The  impulse  of  the  apex  is  feeble,  and 
may  be  suppressed.     The  movements  of  the  organ,  owing  to  the 


PHYSICAL    SIGNS    OF    DILATATION".  .        83 

extended  space  in  which  it  is  in  contact  with  the  thoracic  walls, 
are  sometimes  obscurely  felt,  and  oftener  visible  in  two,  three,  and 
even  four  intercostal  spaces,  which  together  present  an  appearance 
of  fluctuation,  or,  as  called  by  Dr.  AValshe,  quasi  undulation.  In 
some  cases  in  which  the  thoracic  walls  are  thin,  and  the  intercostal 
spaces  wide,  the  heart,  as  has  been  remarked,  seems  to  be  almost 
exposed  to  the  vision  and  touch."  Auscultation  furnishes  certain 
distinctive  points  pertaining  to  the  heart  sounds.  Both  sounds  are 
feeble  in  comparison  with  their  augmented  intensity  in  cases  of 
hypertrophy,  but  the  first  sound  is  disproportionately  weakened. 
The  first  sound  is  still  more  altered  in  character ;  it  becomes  short 
and  valvular,  resembling  in  these  respects  the  second  sound.  The 
latter  alteration,  although  distinctive  of  dilatation,  as  contrasted 
with  hypertrophy,  is  not  peculiar  to  the  former,  and  its  true  ex- 
planation has  not  been  understood.  It  is  due  to  the  absence  of 
the  element  of  impulsion  in  the  first  sound.  This  element  is  defi- 
cient or  wanting  whenever  the  left  ventricle  lacks  the  muscular 
power  necessary  for  its  production.  In  hypertrophy  this  element 
is  exa2;2ferated  owing  to  the  increased  force  of  the  ventricular  con- 
tractions ;  and  in  dilatation  it  is  feeble  or  absent  owing  to  the 
feebleness  which  at  the  same  time  render  the  apex-beat  weak  or 
inappreciable.  But  this  element  is  also  impaired  or  eliminated 
when,  from  other  causes  than  dilatation,  the  muscular  power  of  the 
heart  is  weakened.  The  intensity  of  the  first  sound  is  diminished 
disproportionately  to  that  of  the  second  sound,  and  it  is  also  short 
and  valvular  like  the  second  sound,  in  cases  of  fatty  degeneration, 
softening  in  typhus  fever,  and  even  of  hypertrophy,  when  the  power 
of  the  ventricular  walls  is  greatly  reduced.  An  adventitious  sound 
or  murmur  is  said  to  accompany  the  first  or  systolic  sound  in  some 
instances  of  dilatation  not  complicated  with  valvular  lesions.  As 
a  rule,  a  murmur  is  not  present  unless  the  latter  coexist,  or  the 
blood  have  undergone  those  abnormal  changes  which  occasion  a 
murmur  without  any  organic  afi'ection  of  the  heart.  This  point 
will  be  noticed  in  treating  of  murmurs  in  connection  with  valvular 
lesions.  Inspection  shows  in  certain  cases  the  quasi-undulatory 
movements  within  the  prsecordia  which  have  been  mentioned  as 
also  determinable  by  palpation.  They  are  better  perceived  by  the 
eye  than  by  the  touch.  Inspection  and  mensuration  may  show  an 
abnormal  prominence  of  the  prsecordia.     In  the  rare  cases  of  dila- 

'  Racle,  op.  cit. 


84  ENLARGEMENT    OF    THE    HEART, 

tation  with  attenuated  walls,  it  may  be  true  that  enlargement  of 
the  prsecordia  never  occurs.  This  is  not  true,  however,  of  all  the 
cases  in  which  dilatation  predominates  over  hypertrophy.  With- 
out discussing  the  question  whether  enlargement  by  dilatation  as 
well  as  by  hypertrophy  may  not  give  rise  to  prsecordial  projection, 
this  result  may  be  produced  by  the  hypertrophy  before  the  super- 
vention of  dilatation  which  subsequently  becomes  predominant. 
Absence  of  prsecordial  prominence  does  not  then  belong  among  the 
negative  signs  of  enlargement  by  dilatation. 

Inlhe  diagnosis  of  enlargement  by  dilatation,  assuming  the  fact 
of  enlargement  to  be  ascertained,  symptoms  (as  distinguished  from 
signs)  have  considerable  weight.  Passive  congestions,  lividity, 
feeble  pulse,  and  dropsical  effusion,  in  fact,  constitute  evidence 
almost,  if  not  quite,  conclusive.  The  obstruction  due  to  valvular 
lesions  so  generally  associated  with  enlargement,  it  is  true,  contri- 
bute towards  the  production  of  these  symptoms ;  but,  as  will  be 
seen  when  valvular  lesions  are  considered,  the  obstruction  due  to 
these  rarely,  if  ever,  give  rise  to  the  effects  just  mentioned  until 
dilatation  of  the  cavities  of  the  heart  has  taken  place.  With  the 
aid  of  the  physical  signs,  the  discrimination  between  predominant 
dilatation  and  predominant  hypertrophy  may  generally  be  made 
with  confidence.  The  cases  in  which  there  is  room  for  .doubt  are 
those  of  hypertrophy  when,  from  any  cause,  the  muscular  power  of 
the  heart  is  notably  weakened.  The  differential  diagnosis  is  of 
importance  with  reference  to  prognosis  and  treatment.  The  pros- 
pect of  life  and  tolerable  health  is  less  in  proportion  as  dilatation 
predominates,  and  the  management  involves  attention  to  incidental 
events,  which  do  not  occur  so  long  as  hypertrophy  preponderates. 
For  the  convenience  of  comparison  with  the  physical  signs  distinct- 
ive of  hypertrophy  (see  page  71),  the  signs  distinctive  of  dilatation 
are  embraced  in  the  following  summary. 

SUMMARY  OF  THE  PHYSICAL  SIGNS  DISTINCTIVE  OF  ENLARGEMENT  BY  DILATATION. 

1.  Percussion. — The  transverse  dimensions  of  the  space  occupied 
by  the  heart  greatly  exceeding  the  vertical,  the  form  of  this  space 
corresponding  to  the  wedge-like  or  square  form  of  the  organ  when 
the  dilatation  is  excessive. 

2.  Palpation. — The  apex-beat  devoid  of  abnormal  force  and  in 
some  instances  suppressed.  Absence  of  heaving  movement  of  the 
ribs  and  prsecordia. 


TREATMENT    OF    DILATATION.  85 

3.  Auscultation. — The  element  of  impulsion  of  the  first  sound 
deficient  or  absent,  and  the  sound  short  and  valvular,  in  these 
respects  resembling  the  second  sound. 


Treatment  op  Dilatation. 

With  certain  qualifications,  the  indications  for  the  treatment  of 
dilatation  are  the  same  as  in  cases  of  predominant  hypertrophy. 
The  impediment  to  the  circulation  dependent  on  the  lesions  which 
coexist  in  the  great  majority  of  cases  cannot  be  removed,  but  the 
effects  may  be  mitigated  by  avoiding  extrinsic  causes  which  excite 
unduly  the  action  of  the  heart.  Bloodletting  is  called  for  much, 
more  rarely,  and  is  to  be  employed  with  greater  circumspection 
than  when  hypertrophy  preponderates.  Limiting  the  attention  to 
the  diminution  of  the  mass  of  blood,  it  might  seem  that  this  mea- 
sure would  fulfil  an  important  indication.  But  it  is  to  be  con- 
sidered that  bloodletting  impoverishes  the  blood  by  its  spoliative 
effects,  and  the  secondary  consequences  are  weakness  and  irrita- 
bility of  the  muscular  structure  of  the  heart.  These  consequences 
are  hurtful  to  an  extent  greatly  overbalancing  the  advantage  of 
temporarily  diminishing  the  quantity  of  blood  to  be  circulated. 
Before  resorting  to  this  therapeutical  measure,  the  physician  should 
be  satisfied  not  only  that  the  impediment  is  aggravated  by  an  over- 
plus of  the  mass  of  blood,  but  that  the  organized  elements,  viz.,  the 
corpuscles,  which  are  disproportionately  diminished  by  bloodletting, 
are  not  already  deficient.  No  advantage  to  be  derived  from  this 
measure  can  compensate  for  the  evils  of  anaemia.  Bearing  in  mind 
the  immediate  effects  of  bloodletting  on  the  composition  of  the 
blood,  and  the  secondary  effects,  due  to  impoverished  blood,  on  the 
muscular  structure,  the  cases  in  which  it  is  called  for  seldom,  if 
ever,  occur.  These  remarks  will,  measurably,  but  not  nearly  to  the 
same  extent,  apply  to  other  methods  of  depletion,  viz.,  saline  pur- 
gatives and  diuretics.  Perhaps  it  may  be  said  that  in  cases  of 
dilatation  the  latter  methods  should  be  employed  to  the  entire 
exclusion  of  bloodletting.  Excessive  muscular  exercise,  mental 
excitement,  and  other  extrinsic  causes  exciting  unduly  the  action 
of  the  heart,  are  to  be  avoided.  Warmth  of  the  external  surface, 
and  revulsive  measures  to  attract  blood  to  the  extremities,  are 
indicated  oftener  and  more  strongly  in  cases  of  dilatation  than  in 
cases  of  hypertrophy. 


86  ENLARGEMENT    OF    THE    HEART. 

The  measures  which,  in  hypertrophy  are  pursued  in  order  to 
prevent  dilatation,  are  not  less  indicated  when  the  latter  exists. 
The  great  end  in  the  management  is  to  increase  the  muscular 
power  of  the  heart.  For  this  end,  the  diet  should  be  as  highly 
nutritious  as  possible,  and  the  quantity  of  liquid  ingesta  as  small  as 
is  compatible  with  comfort.  In  the  arrangement  of  diet,  the  state 
of  the  digestive  organs  is  to  be  consulted.  Imperfect  or  labored 
digestion  involves  excited  action  of  the  heart,  and  is  to  be  carefully 
avoided.  When  indigestion  exists,  palliative  remedies  are  to  be 
prescribed ;  and  remedies  to  improve  the  digestive  function,  viz., 
tonics  and  the  judicious  use  of  stimulants,  constitute  an  important 
part  of  the  treatment.  Preparations  of  iron  are  especially  indicated 
if  there  be  anaemia.  Constipation  is  to  be  prevented.  Exercise, 
within  certain  limits,  is  to  be  enjoined.  The  injury  arising  from 
excessive  muscular  exertion  has  been  referred  to;  but  an  extreme 
of  quietude  is  not  less  hurtful,  IIow  is  the  judicious  mean  to  be 
determined?  The  experience  of  the  patient  must  be  the  guide. 
An  amount  or  kind  of  exercise  which  excites  unduly  the  action  of 
the  heart  or  occasions  dyspnoea  is  to  be  abstained  from ;  but  exer- 
cise short  of  these  effects  will  be  useful.  Patients  who  follow 
avocations  which  involve  manual  labor  will,  in  general,  do  better 
to  pursue  their  callings,  observing  the  precaution  just  mentioned, 
than  to  relinquish  all  occupation.  The  necessity  for  an  undue 
amount  of  labor  in  order  to  obtain  a  livelihood  is  a  calamity  for 
persons  affected  with  cardiac  disease ;  but  a  condition  in  life  in 
which  there  is  no  other  motive  for  exertion  than  the  attainment  of 
health  is  sometimes  equally  calamitous.  Patients  of  the  latter  class 
should  be  encouraged  to  engage  in  sports  which  afford  the  requisite 
exercise,  and,  at  the  same  time,  interest  the  mind,  such  as  shooting, 
fishing,  and  travelling.  An  advantage  of  no  small  account,  inci- 
dental to  pursuits  which  involve  both  exercise  and  mental  occupa- 
tion, accrues  from  the  diversion  of  mind  and  cheerfulness  which 
they  promote.  Depression  and  gloomy  forebodings  are  to  be 
obviated  as  far  as  possible,  and  with  a  view  to  this,  as  much 
encouragement  should  be  given  as  the  nature  of  the  case  will 
permit.  In  a  large  proportion  of  the  cases  which  the  physician 
meets  with  in  practice,  he  may  conscientiously  encourage  hopes, 
not  of  cure,  but  of  tolerable  health  for  an  indefinite  period.  The 
common  notion  that  disease  of  heart  generally  ends  in  sudden 
death  may  be  removed  by  positive  assurances  of  its  falsity. 

Eemedies   to   allay  undue  excitement  and   irregularity  of  the 


TEEATMENT    OF    DILATATION.  87 

heart's  action  are  indicated  in  cases  of  dilatation,  as  well  as  in  cases 
of  hypertrophy.  The  same  remedies  are  indicated  in  both  forms  of 
enlargement ;  but  they  are  to  be  employed  with  more  caution  in  the 
former  than  in  the  latter.  The  danger  of  weakening  or  retarding 
too  much  the  muscular  action  of  the  heart  is  far  greater  in  cases  of 
dilatation.  Anodynes,  digitalis,  aconite,  etc.,  are  serviceable,  but 
must  not  be  pushed  beyond  the  effect  of  tranquillizing  the  action  of 
the  heart,  incurring  risk  of  weakening  the  muscular  power  of  the 
organ. 

The  paroxysms  of  dyspnoea  or  orthopnoea,  sometimes  the  source 
of  great  distress  in  cases  of  dilatation,  are  to  be  palliated  by  anti- 
spasmodic remedies  and  revulsive  applications.  Of  the  former,  the 
ethers,  and  of  the  latter,  sinapisms,  dry  cupping,  and  stimulating 
pediluvia  are  the  most  efficient. 

The  treatment  of  dropsy  dependent  on  cardiac  disease  is  deferred 
till  after  the  consideration  of  valvular  lesions. 


CHAPTER    II. 

LESIONS,  EXCLUSIVE   OF   ENLARGEMENT,  AFFECT- 
ING   THE   WALLS   OF   THE   HEART. 

Atrophy,  •witli  diminished  bulk  of  heart — Fatty  growth  and  degeneration — Symptoms  and 
pathological  effects  of  fatty  growth  and  degeneration — Physical  signs  and  diagnosis  of 
fatty  growth  and  degeneration — Treatment  of  fatty  growth  and  degeneration — Softening 
of  the  heart  in  typhus  and  typhoid  fever  and  other  affections — Treatment  of  softening 
of  the  heart — Induration  of  the  heart — Cardiac  aneurism — Rupture  of  the  heart — Car- 
cinoma, tuberculosis,  extravasation  of  blood  and  cysts. 

Exclusive  of  enlargement,  the  heart  is  liable  to  various  lesions 
affecting  the  walls  of  the  organ,  to  some  of  which  allusion  has  been 
already  made,  as  standing  in  a  causative  relation  to  dilatation. 
Atrophy,  with  diminished  bulk  of  the  heart,  is  one  of  these  ;  fatty 
growth  and  degeneration  constitute  others ;  other  lesions  are,  soft- 
ening and  induration,  and  in  this  category  may  be  included  aneu- 
rism of  the  heart  and  rupture.  This  chapter  will  be  devoted  to  the 
consideration  of  these  different  organic  affections,  taken  up  in  the 
order  in  which  they  have  just  been  mentioned. 


ATROPHY   WITH    DIMINISHED    BULK    OF    THE    HEART. 


The  muscular  substance  of  the  heart  is  sometimes  diminished,  the 
cavities  not  being  enlarged,  but,  on  the  contrary,  their  capacity 
lessened.  The  organ  is  reduced  in  size  below  the  normal  limits. 
In  the  adult  subject  it  may  resemble  in  bulk  the  heart  of  a  child. 
The  weight  corresponds  to  the  diminution  in  size.  This  reduction 
in  size  and  weight  does  not  involve  necessarily  any  notable  change 
in  the  appearance  of  the  organ  in  other  respects,  the  only  obvious 
deviation  from  the  normal  condition  being  the  diminution  in  volume 
and  in  the  thickness  of  the  ventricular  walls. 


ATROPHY    OF    HEART.  89 

This  is  undoubtedly  to  be  considered  as  an  organic  affection  of 
the  heart,  but  it  very  rarely,  if  ever,  occurs  except  in  harmony,  so 
to  speak,  with  other  morbid  conditions,  and  under  circumstances 
in  which  it  neither  occasions  unpleasant  consequences,  nor  claims 
attention  in  a  therapeutical  point  of  view.  It  is  incidental  to 
chronic  diseases  of  long  duration,  characterized  by  gradual,  pro- 
gressive emaciation.  It  is  observed  in  some  cases  of  pulmonary 
tuberculosis,  and  more  especially  in  cases  of  carcinoma.  It  is  said 
to  follow,  in  some  instances,  pericardial  adhesions  and  calcification 
of  the  coronary  arteries ;  but  its  dependence  on  these  lesions  does 
not  appear  to  be  established.  It  is  observed,  in  some  instances,  in 
connection  with  a  superabundance  of  fat  on  the  exterior  of  the 
heart,  and  may  be  due,  in  these  instances,  as  in  cases  of  pericardial 
adhesions,  to  mechanical  pressure  of  the  organ  continued  for  a  long 
period.  The  conditions  generally  giving  rise  to  it  are  diminution 
of  the  mass  of  blood,  and  of  its  nutritive  materials — conditions  in- 
volving diminished  exertion  of  the  muscular  power  of  the  organ. 
The  heart  wastes  like  other  muscles  when  badly  nourished  and  in- 
sufficiently exercised.  But,  under  the  circumstances,  that  is,  in 
view  of  coexisting  tuberculosis,  or  carcinoma,  or  some  other  affec- 
tion, which,  like  these,  terminates  fatally  after  slowly  progressive 
emaciation,  the  cardiac  atrophy,  so  far  from  being  an  evil,  may 
perhaps  belong  among  the  conservative  provisions  of  which  the 
pathological  history  of  even  the  most  fatal  forms  of  disease  furnishes 
illustrations. 

The  symptoms  of  atrophy  of  the  heart,  it  is  sufficiently  clear, 
must  be  those  which  denote  feebleness  of  the  circulation ;  but  in- 
asmuch as  an  enfeebled  circulation  due  to  other  morbid  conditions, 
precedes  and  gives  rise  to  the  atrophy,  it  must  be  difficult  to  decide 
to  what  extent  the  symptoms  are  dependent  on  the  latter.  Nor 
are  the  symptoms  denoting  feebleness  of  the  circulation  distinctive 
of  this  particular  lesion  of  the  heart.  They  are  incident  alike  to 
dilatation,  fatty  degeneration,  softening,  &c.  The  physical  signs 
are  much  more  distinctive,  and,  in  fact,  suffice  for  the  diagnosis. 
The  boundaries  of  the  superficial  and  deep  cardiac  regions  are 
within  the  extreme  limits  of  health;  the  apex-beat  is  indistinct  or 
wanting,  and  the  heart-sounds  are  abnormally  feeble,  and  may  be 
inappreciable.  In  a  patient  under  observation  at  the  time  I  am 
writing,  a  clear,  vesicular  resonance  on  percussion  is  elicited  over 
the  entire  priecordia.  The  respiratory  murmur  is  quite  intense 
and  normal  over  the  whole  prtecordial  space,  a  fact  which  excludes 


90         LESIONS    AFFECTING   THE    AVALLS    OF    THE    HEART. 

emphysema  of  the  portion  of  lung  overlapping  the  heart.  There  is 
in  this  case  no  superficial  cardiac  region ;  the  anterior  borders  of 
the  heart  appear  to  meet.  The  left  boundary  of  the  deep  cardiac 
region  is  sufficiently  defined  by  the  percussion-sound,  and  falls  half 
an  inch  within  the  nipple.  The  apex-beat  is  not  felt,  and  the  heart- 
sounds  are  nowhere  discoverable.  There  is  evidently  considerable 
atroph}'-  in  this  case,  yet  there  are  no  symptoms  pointing  to  cardiac 
disease.  The  patient  has  for  several  years  been  affected  with  pul- 
monary tuberculosis,  which  is  either  non-progressive,  or  advancing 
very  slowly.^ 

As  already  stated,  atrophy  of  the  heart  does  not  call  for  medical 
treatment. 


FATTY   GROWTH   AND   DEGENERATION. 

"With  the  undue  accumulation  of  fat  are  connected  lesions  quite 
different  in  character  and  importance,  according  to  the  difference 
of  situation  in  which  the  fat  accumulates.  More  or  less  fat  is  gene- 
rally present  in  health  on  the  outer  surface  of  the  heart  after  early 
infancy,  especially  on  the  right  ventricle,  at  and  near  the  base  of 
the  organ.  It  accumulates  in  this  situation  to  an  abnormal  extent 
in  some  cases.  A  moderate  amount  of  over-accumulation  is  fre- 
quently met  with  in  post-mortem  examinations,  when  there  had 
been  during  life  no  symptoms  of  heart  disease.  If  the  quantity  do 
not  considerably  exceed  the  normal  average,  although  it  must  in 
some  measure  embarrass  the  movements  of  the  organ,  it  does  not 
occasion  any  serious  results  or  appreciable  inconvenience.  When 
the  accumulation  is  excessive,  however,  from  its  weight  it  leads  to 
enfeebled  muscular  action  and  consequent  weakness  of  the  circula- 
tion. It  may  also  favor  dilatation  if,  from  other  causes,  the  blood 
accumulate  unduly  within  the  cavities  of  the  heart.  "Without 
these  concurrent  causes,  it  may  induce  atrophy  with  diminished 
size  of  the  muscular  portion  of  the  heart.  This  variety  of  fatty 
heart  occurs  after  the  middle  period  of  life,  in  persons  who  present 
evidence  of  an  "adipose  diaihesis,''^  viz :  accumulation  of  fat  in 

'  Case  of  Thos.  Carr,  Hospital  Records,  vol.  xiii.  page  87- 

2  This  term  is  borrowed  from  my  friend,  Prof.  Gross.  Elements  of  Pathological 
Anatomy,  third  edition,  1857.  Dr.  Bellingham  also  makes  use  of  the  term  "  fatty 
diathesis."     Treatise  on  Heart,  part  ii.,  1857. 


FATTY  GROWTH  AND  DEGENERATION.         91 

different  organs  and  beneath  the  integument,  constituting  corpu- 
lency. Not  unfrequently,  however,  it  occurs  in  persons  who  are 
not  corpulent.'  The  heart  is  sometimes  completely  encased  in  a 
thick  layer  of  adipose  substance,  which  alters,  in  a  marked  degree, 
the  external  appearance  and  form  of  the  organ.  The  volume  of 
the  heart  is  often  increased  not  alone  by  the  fatty  deposit,  but  by 
more  or  less  dilatation.  Beneath  the  fatty  layer  the  muscular  sub- 
stance may  not  present  any  structural  change.  It  is,  however, 
generally  unusually  pale,  and  the  texture  softened. 

The  extension  of  fatty  growth  between  the  muscular  fibres  is 
followed  by  more  serious  consequences  than  when  the  deposit  is 
limited  to  the  surface  of  the  organ.  The  pressure  upon  the  fibres 
induces  greater  functional  weakness,  and,  at  length,  atrophy.  The 
power  of  the  heart  in  propelling  the  currents  of  blood  and  in  resist- 
ing the  force  of  distension  from  accumulation  within  the  cavities  is 
proportionately  lessened.  Hence,  feebleness  of  the  circulation  and 
proneness  to  dilatation  in  proportion  to  the  amount  of  deposit  in 
this  situation.  The  deposit  in  this  situation  may  be  in  the  form  of 
adipose  vesicles  and  infiltrated  oily  matter. 

Another  variety,  much  more  serious,  and  differing  essentially  in 
character,  is  that  commonly  known  as  fatty  degeneration.  The  fat 
is  deposited  in  the  form  of  oil-globules  within  the  sarcolemma.  It 
replaces  the  muscular  substance  and  constitutes  another  form  of 
fatty  atrophy.  This  variety  may  be  associated  with  the  preceding 
varieties  of  fatty  heart,  but  it  occurs  independently  of  the  latter. 
It  affects  more  especially  the  left  ventricle,  while  the  varieties  con- 
sisting of  abnormal  growth  of  the  adipose  vesicles  are  most  abund- 
ant on  and  within  the  right  ventricles.  It  may  be  pretty  uniformly 
diffused  over  the  left  ventricle  or  the  whole  heart,  but  it  is  oftener 
confined  to  circumscribed  patches  or  strips.  The  portions  affected 
assume  a  yellowish  or  fawn  color,  which  is  somewhat  characteristic, 
and  if  the  heart  be  affected  in  disseminated  patches  it  presents  a 
mottled  aspect.  Examined  with  the  microscope,  the  striae  or  trans- 
verse markings  of  the  fibres  are  indistinct  or  wanting,  and  in  place 
of  the  proper  contents  of  the  sarcolemma,  it  contains  oil-globules 
in  more  or  less  abundance  according  to  the  amount  of  degeneration. 
It  is  evident  that  in  proportion  to  the  degree  and  extent  of  this 

'  Of  49  cases  analyzed  by  Dr.  T.  K.  Chambers  (Decennium  Pathologicum) ,  it  was 
associated  with  general  corpulence  in  20,  and  occurred  in  persons  not  corpulent  in 
29.      Vide  Bellingham,  op.  cit.  part  ii. 


92         LESIOXS    AFFECTING    THE    WALLS    OF    THE    HEART. 

stractural  change,  the  muscular  power  of  the  heart  must  be  irre- 
coverably weakened.  It  is  proportionately  incapacitated  to  propel 
the  blood  with  adequate  force,  and  more  readily  yields  to  distension 
from  the  accumulation  of  blood.  The  portions  of  the  organ  which 
have  undergone  fatty  degeneration  are  soft  and  friable,  and  it  will 
be  seen  presently  that  when  rupture  of  the  heart  takes  place,  it  is 
owing  generally  to  this  structural  change  having  occurred.  Cases 
are  reported  in  which  apparently  the  greater  part  of  the  muscular 
substance  had  disappeared,  the  fibres  preserving  their  outline,  but 
containing  fat  instead  of  their  proper  anatomical  elements.  The 
auricles  may  be  the  seat  of  this  fatty  change,  but  much  more  rarely 
than  the  ventricles.  For  a  fuller  description  of  the  gross  and 
microscopical  appearances  presented  in  fatty  degeneration,  the 
reader  is  referred  to  works  on  morbid  anatomy.^ 

The  distinct  pathological  character  of  fatty  degeneration,  as 
compared  with  fatty  growth  upon  the  heart  and  between  the 
muscular  fibres,  is  a  point  of  importance.  The  latter  is,  in  fact, 
hypertrophy  of  the  adipose  tissue,  while  the  former  involves  more 
properly  an  abnormal  deposit.  The  term  degeneration  implies  a 
conversion  of  the  muscular  substance  into  fat.  That  the  mechan- 
ism of  fatty  degeneration  does  involve  this  transformation  is  the 
view  entertained  by  some  distinguished  pathologists.^  The  mus- 
cular substance,  according  to  this  view,  undergoes  a  metamorphosis, 
the  same  elements  recombining  to  form  the  fatty  matter,  as  muscu- 
lar tissue  after  death  is  supposed  to  be  converted  into  adipocere. 
If  this  view  be  correct,  it  is  not  strictly  accurate  to  call  the  fatty 
matter  a  deposit ;  it  is  not,  at  all  events,  deposited  primarily  as  fat, 
but  as  the  substance  of  the  muscle.  Nor  is  the  change  due  to 
perverted  nutrition ;  it  is  due  to  a  chemical,  not  a  vital  process.  A 
more  philosophical  explanation  attributes  the  change  to  a  process 
of  replacement  rather  than  conversion.  The  fat  is  strictly  an 
abnormal  deposit,  which  takes  the  place  of  the  muscular  substance. 
The  change,  agreeably  to  this  explanation,  does  not  consist,  pro- 
perly speaking,  in  a  degeneration  of  structure,  but  in  the  substitu- 
tion of  one  anatomical  element  for  another,  and  it  has  been  proposed 
to  employ,  as  a  more  accurate  mode  of  expression,  the  term  suhsti- 

'  Rokitansky  and  Jones  &  Sieveking  may  be  consulted  for  this  object. 

^  For  the  evidence  to  be  adduced  in  support  of  this  doctrine,  the  reader  is 
referred  to  an  article  by  Dr.  Richard  Quain  (in  Medico- Chirurgical  Transactions, 
vol.  sxxiii.)  on  Fatty  Disease  of  the  Heart. 


FATTY    GROWTH    AND    DEGENERATION".  93 

tution  instead  of  degeneration.'  Thej  who  adopt  the  latter  view 
regard  atrophy  of  the  muscular  tissue  as  the  first  step  in  the  local 
pathological  process.  The  anatomical  elements  within  the  sarco- 
lemma  disappear  by  absorption,  and  fat  is  deposited  in  their  place. 
It  is,  perhaps,  as  reasonable  to  suppose  that  the  primary  change  is 
the  fatty  deposit,  the  removal  of  the  anatomical  elements  of  the 
muscular  tissue  taking  place  subsequently,  the  atrophy  thus  being 
not  a  prior,  but  a  consecutive  condition. 

On  what  antecedent  morbid  conditions  are  the  different  forms  of 
fatty  disease  of  heart  dependent  ?  Morbid  growth  or  hypertrophy 
of  the  adipose  tissue,  as  already  stated,  is  often  associated  with  that 
tendency  to  superabundance  of  fat  which  constitutes  obesity.  This 
tendency  is  directed  towards  the  heart,  after  middle  life,  in  persons 
of  indolent  and  luxurious  habits,  and  who  are  addicted  to  the  use 
of  alcoholic  beverages.  Active  exercise  and  a  well-regulated  diet 
serve  to  protect  the  heart  against  accumulation  of  fat,  even  when 
the  adipose  diathesis  is  marked.  Fatty  degeneration  occurs  inde- 
pendently of  this  diathesis.  The  conditions  on  which  it  depends 
are  not  well  ascertained.  It  is  a  question  w^hether  it  involves  a 
prior  alteration  of  the  blood,  or  is  to  be  regarded  as  an  effect  of 
conditions  purely  local.  The  latter  view  is  favored  by  the  doctrine 
that  muscular  atrophy  precedes  the  fatty  deposit ;  and,  on  the  other 
hand,  if  the  deposit  takes  precedence,  a  predisposing  condition  of 
the  blood  is  reasonably  inferred.  The  latter  supposition  is  sustained 
by  the  fact  that,  although  this  variety  of  fatty  heart  occurs  in  per- 
sons who  are  not  corpulent,  it  is  usually  found  in  association  with 
fatty  degeneration  in  other  parts,  especially  the  liver,  spleen,  and 
the  arterial  coats.  This  fact  points  to  a  blood-crasis  or  diathesis. 
Prof.  R.  W,  Smith,  of  Dublin,  has  reported  cases  in  which  free  oil 
was  collected,  after  death,  in  considerable  quantity,  from  the  blood 
contained  in  the  vessels  and  heart-cavities.^  As  suggested  by  Robin, 
the  oil  in  these  cases  may  have  exuded  from  the  tissues  as  a  result 
of  post-mortem  decomposition,  and  in  one  of  the  cases  its  presence 
in  the  cavities  of  the  heart  may  be  explained  by  the  fact  that  rup- 
ture of  the  ventricle  had  occurred.  Dr.  Quain,  who  regards  the 
change  as  a  conversion  of  elements,  attributes  the  affection  to  im- 
paired nutrition,  frequently  dependent  on  coexisting  obstruction  of 

'  Cli.  Robin,  vide  Chimie  Anatomique  ;  also  Dictionnaire  de  Medeciue  (Nysten), 
1855,  art.  Degeneration. 

2  These  cases  are  reported  in  the  Dublin  Journal  of  Medical  Science,  first  series, 
vol.  is.  p.  411.     See  Stokes  on  Diseases  of  the  Heart  and  Aorta. 


9i         LESIOXS    AFFECTIXG    THE    WALLS    OF    THE    HEART. 

the  coronary  arteries.  Of  eighty-three  cases  analyzed  by  him,  these 
arteries  were  ossified  or  obstructed  in  twenty-five.  Eokitansky, 
having  observed  it  often  in  connection  with  pericarditis  and  endo- 
carditis, thinks  it  may  occur  as  a  sequel  of  these  affections.  It  is 
observed  in  cases  of  enlargement.  Of  forty-nine  cases  analyzed  by 
Dr.  T.  K.  Chambers,  the  heart  was  enlarged  in  twenty-nine.  In 
twenty-three  of  these  cases  dilatation  predominated.  Its  occurrence 
with  other  causes  doubtless  contributes  to  dilatation;  but,  in  view 
of  the  infrequency  of  the  latter,  except  in  connection  with  valvular 
or  other  affections  impeding  the  circulation,  it  cannot  often  be  re- 
ferred exclusively  to  fatty  degeneration.  On  the  other  hand,  it  is 
not  improbable  that  enlargement  of  the  heart  may  lead  to  fatty 
degeneration.'     This  opinion  is  held  by  Eokitansky. 


Symptoms  and  Pathological  Effects  of  Fatty  Growth  and  Deposit. 

Although  the  different  forms  of  fatty  disease  differ  pathologi- 
cally, their  general  effects  are  similar.  They  induce  alike  weakness 
of  the  heart,  and  symptomatic  phenomena  due  to  enfeebled  circu- 
lation. But  they  by  no  means  induce  these  effects  in  an  equal 
degree.  A  considerable  accumulation  of  fat  upon  the  heart,  as 
stated  already,  may  exist  without  giving  rise  to  symptoms  which 
point  to  cardiac  disease.  The  effects  are  more  marked  if  the  fatty 
substance  penetrate  between  the  muscular  fibres,  or  if  the  organ 
become  infiltrated  with  fatty  matter.  They  are  still  more  strongly 
marked  in  cases  of  oily  degeneration  in  which  atrophy  of  the  mus- 
cular tissue  has  occurred  to  much  extent.  Each  variety,  of  course, 
is  important,  or  serious,  in  proportion  to  its  diS'usion  and  amount ; 
but  microscopical  observers  have  found  considerable  degeneration 
in  hearts  in  which  disease  had  not  been  suspected  either  from  the 
symptoms  during  life  or  the  general  appearance  after  death.     The 

'  Mr.  Grant,  of  London,  has  lately  investigated  the  pathological  conditions  in 
cattle  fattened  for  exhibition,  and  finds  that  fatty  degeneration  of  the  muscular 
tissue,  and  especially  of  the  heart,  is  a  uniform  result  of  the  system  of  overfeeding 
pursued.  This  is  of  importance  with  reference  to  the  connection  of  fatty  degenera- 
tion and  dietetic  habits  in  the  human  species.  Vide  "  Evil  Results  of  Overfeeding 
Cattle.  A  new  inquiry,  fully  illustrated  by  colored  engravings  of  the  heart,  lungs, 
etc.,  of  the  diseased  prize  cattle  lately  exhibited  by  the  Smithfield  Cattle  Club, 
1857.  By  Frederick  James  Grant,  M.  R.  C.  S.,  etc.  London,  1858."  {Brit,  and 
For.  Med.-Chir.  Rev.,  July,  1858.) 


FATTY    GROWTH    AND    DEGENERATION.  95 

great  extent  and  degree  of  degeneration  found  in  some  instances 
are  remarkable. 

The  symptomatic  phenomena  referable  directly  to  the  heart  and 
circulation  (exclasive  of  physical  signs)  are  not  distinctive.  The 
pulse,  if  the  heart  be  not  very  greatly  weakened,  may  be  natural 
in  frequency  and  perfectly  regular.  It  will  lack  force;  but  the  dif- 
ferences in  this  respect  are  so  great  among  healthy  persons,  owing 
to  a  variety  of  circumstances,  that  this  quality  of  the  pulse  does 
not  possess  much  significance.  Notable  slowness  of  the  pulse  has 
been  observed,  the  number  of  pulses  per  minute  falling  to  twenty 
or  thirty,  and  even  much  lower  in  some  cases.  They  have  been 
observed  as  low  as  eight  and  nine  per  minute.^  In  an  advanced 
stage  of  disease,  intermittency,  irregularity,  and  great  frequency, 
conjoined  with  extreme  feebleness,  are  liable  to  occur.  These  cha- 
racters, however,  belong  equally  to  the  pulse  in  cases  of  dilatation ; 
they  do  not  indicate  specially,  of  themselves,  fatty  disease.  The 
pulse  and  systemic  circulation  will,  of  course,  furnish  manifesta- 
tions of  cardiac  weakness  more  marked  in  proportion  as  the  disease 
affects  the  left  ventricle.  General  dropsy  does  not  occur  as  a  result 
of  merely  weakness  of  the  heart,  exclusive  of  valvular  lesions  and 
dilatation.  Sense  of  oppression  at  the  pr^ecordia,  palpitation,  and 
a  tendency  to  syncope,  are  other  symptoms  referable  directly  to  the 
heart  and  circulation.  I  have  also  observed  a  notable  degree  of 
capillary  congestion  of  the  extremities. 

Dyspnoea  on  exercise  is  present  in  proportion  as  the  right  ven- 
tricle is  weakened.  But  this  symptom  does  not  represent  exclu- 
sively weakness  of  this  ventricle.  If  the  contractions  of  the  left 
ventricle  are  feeble  and  incomplete,  the  left  auricle  necessarily  be- 
comes distended,  and  pulmonary  congestion  ensues.  Hence  more 
or  less  dyspnoea  is  present  when  fatty  degeneration  is  confined  to 
the  left  ventricle,  provided  its  muscular  power  be  considerably 
compromised. 

These  and  other  symptoms  which  might  be  mentioned  are  com- 
mon to  all  affections  compromising,  beyond  certain  limits,  the  power 
of  the  heart's  action.  They  point  only  to  some  cardiac  trouble  in- 
volving diminished  power  of  the  organ.  Considered  alone,  they 
are  not  diagnostic  of  the  affections  under  consideration. 

•  Vide  memoir  on  "Slow  Pulse,"  by  Mr.  Ricliardson,  Dublin  Quarterly  Journal, 
vol.  xiv.  Dr.  Bellingliam  remarks,  with  reason,  that  this  ahnormal  slowness  in- 
volves an  abnormal  cerebral  condition  superadded  to  the  heart-affection. 


96         LESIONS    AFFECTING    THE    WALLS    OF    THE    HEART. 

Certain  events  pertaining  to  the  nervous  and  respiratory  systems 
have  been  supposed  to  be  highly  significant  of  fatty  degeneration 
of  the  heart.  The  occurrence  of  seizures  resembling  apoplexy, 
appears  to  have  been  first  observed  by  Dr.  Cheyne.^  Subsequently 
cases  have  been  reported  by  Drs.  Adams,  Law,  and  Stokes,  of  Dub- 
lin. These  attacks  are  characterized  by  the  sudden  loss  of  con- 
sciousness, and  recovery  without  paralysis.  In  some  cases  they 
recurred  frequentlj-,  in  the  end  proving  fatal,  and  on  dissection  the 
brain  presented  no  morbid  appearances  adequate  to  explain  their 
occurrence.  The  heart  had  undergone  extensive  fatty  change,  and 
the  cavities  were  dilated.^  An  instance,  probably  illustrating  the 
association  of  this  pseudo-apoplectic  affection  and  fatty  degenera- 
tion, the  existence  of  the  latter  being  determined  by  clinical 
evidence,  came  under  my  observation  in  1856,  in  the  case  of  a  hos- 
pital patient,  aged  56,  admitted  in  a  state  of  unconsciousness.  His 
eyes  were  open,  his  expression  vacant,  and  he  made  no  effort  to 
reply  to  questions.  The  skin  was  cool ;  the  pulse  small  and  not 
accelerated.  The  persons  who  brought  him  to  the  hospital  could 
give  no  account  of  the  history,  except  that  he  was  found  in  his 
present  condition.  He  made  no  effort  to  assist  himself  on  his  way 
to  the  hospital.  Eespirations  were  normal.  Brandy  and  nourish- 
ment alone  were  prescribed.  The  next  morning  he  manifested 
some  consciousness,  but  appeared  idiotic ;  smiled  when  questions 
were  put  to  him,  and  said  nothing.  The  following  day  the  im- 
provement was  more  marked.  Said  he  was  quite  well.  Could 
give  no  account  of  his  attack.  He  speedily  convalesced,  and  after- 
wards replied  to  questions  intelligently.  He  declared  that  he  had 
no  recollection  of  his  attack,  nor  of  his  being  brought  to  the  hos- 
pital. The  arcus  senilis  in  this  patient  was  well  marked,  more  so  in 
the  right  than  in  the  left  eye.  The  pulse  was  80,  and  quite  feeble; 
capillary  congestion  marked  on  the  hands,  and  the  face  pallid. 
The  heart-sounds  were  extremely  feeble.  No  impulse  seen  or  felt, 
except  a  very  slight  movement  in  the  epigastrium.  No  murmur. 
He  was  accustomed  to  drink  about  half  a  pint  of  whiskey  daily. 
He  left  the  hospital  after  a  fortnight,  and  the  subsequent  history  is 
unknown. 

'  Dublin  Hospital  Reports,  vol.  ii.  Case  is  reported  in  Stokes  on  Diseases  of 
the  Heart  and  Aorta,  Am.  ed.,  p.  319. 

2  This  statement  with  respect  to  dilatation  applies  to  the  cases  given  by  Dr. 
Stokes,  op.  cit.  The  reader  will  find  the  subject  treated  at  some  length  in  that 
work. 


FATTY  GROWTH  AND  DEGENERATION".         97 

The  nature  of  the  pathological  relation  existing  between  attacks 
of  pseudo-apoplexy  and  the  cardiac  affections  under  consideration, 
with  our  present  knowledge,  can  only  be  conjectured.  That  it 
consists  in  disordered  cerebral  circulation  due  to  the  weakened 
condition  of  the  heart,  is  not  probable,  inasmuch  as  the  muscular 
power  of  the  organ  is  equally  reduced  in  cases  of  simple  and  com- 
plicated dilatation.  It  is  more  rational  to  suppose  that  some  inter- 
mediate morbid  conditions  are  involved ;  conditions  not  dependent 
on  cardiac  disease,  but  associated,  more  or  less  frequently,  with  it. 
In  one  of  the  cases  reported  by  Dr.  Stokes,  calcification  of  the  cere- 
bral arteries  existed  in  a  notable  degree.  In  fact,  further  clinical 
observation  is  necessary  to  establish  the  existence  of  a  fixed  patho- 
logical connection  between  these  attacks  and  fatty  degeneration,  or 
any  disease  of  the  heart.  I  have  met  with  an  instance  in  which 
attacks  analogous  to  those  described  by  the  author  first  named, 
occurred  from  time  to  time  for  several  years,  when  no  other  evi- 
dence of  disease  of  the  heart  existed.  A  gentleman,  aged  33,  of  a 
highly  nervous  temperament,  as  often  as  once  a  month,  without 
any  apparent  exciting  cause,  has  what  are  called  "fainting  fits," 
during  which,  for  a  few  moments,  he  loses  his  consciousness.  The 
extremities  are  cold,  and  sometimes  the  attacks  are  accompanied  by 
slight  rigor.  Febrile  reaction  does  not  follow.  There  are  no  con- 
vulsive movements,  nor  disturbance  of  the  respiration.  The  patient 
consulted  me  under  an  impression  that  there  existed  disease  of  the 
heart,  but  the  phj'-sical  signs  denoted  in  all  respects  a  normal  con- 
dition of  this  organ.  In  addition  to  a  life  of  ease  and  indolence, 
this  gentleman  had  for  years  been  accustomed  to  the  daily  indul- 
gence of  the  venereal  act.' 

A  peculiar  aberration  of  the  respiratory  movements,  first  de- 
scribed by  Dr.  Cheyne,  but  not  considered  by  him  as  significant  of 
any  special  cardiac  lesion,  is  regarded  by  Dr.  Stokes  as  character- 
istic of  great  weakness  of  the  heart  incident  to  fatty  degeneration. 
This  symptom  is  thus  described  by  the  distinguished  author  just 
named :  "  It  consists  in  the  occurrence  of  a  series  of  inspirations, 
increasing  to  a  maximum,  and  then  declining  in  force  and  length, 
until  a  state  of  apparent  apnoea  is  established.  In  this  condition 
the  patient  may  remain  for  such  a  length  of  time  as  to  make  his 
attendants  believe  that  he  is  dead,  when  a  low  inspiration,  followed 
by  one  more  decided,  marks  the  commencement  of  a  new  ascending 

'  Case  of ,  Private  Med.  Records,  vol.  x.  p.  253. 


98         LESIONS    AFFECTING    THE    WALLS    OF    THE    HEART. 

and  then  descending  series  of  inspirations.  This  symptom,  as  occur- 
ring in  its  highest  degree,  I  have  only  seen  during  a  few  weeks 
previous  to  the  death  of  the  patient.'" 

Fatty  degeneration  of  the  iris,  giving  rise  to  the  appearance  well 
known  as  the  arcus  senilis,  has  been  observed  in  cases  of  fatty  de- 
generation of  the  heart.  It  has  been  supposed  to  be  valuable  as  a 
symptom  from  its  frequent  coincidence  with  the  latter.  Its  precise 
value  is  yet  to  be  determined  by  clinical  experience.  It  may  be 
regarded  as  at  least  denoting  a  condition  of  the  system  favorable 
for  fatty  degeneration,  and,  taken  in  connection  with  the  symptoms 
and  signs  relating  directly  to  the  heart,  it  is  not  without  diagnostic 
import.  The  degree  of  significance  which  belongs  to  it  depends,  of 
course,  on  the  frequency  or  constancy  of  the  association.  With 
our  present  knowledge  it  is  certainly  insufficient  as  a  basis  of  the 
diagnosis  of  fatty  degeneration  of  the  heart,  exclusive  of  local 
signs  and  symptoms ;  and,  on  the  other  hand,  its  absence  is  not  to 
be  considered  as  proof  that  the  cardiac  affection  does  not  exist.^ 

According  to  Dr.  Walshe,  failure  of  the  sexual  inclination  and 
power  is  to  be  included  among  the  pathological  effects.  He  states 
that  in  one  of  the  best  marked  cases  of  the  disease  which  he  ever 
saw,  clinically  speaking,  in  a  person  under  forty-five  years  of  age, 
he  was  consulted  for  impotency,  without  reference  to  the  cardiac 
symptoms. 

Paroxysms  of  pain  and  dyspnoea,  constituting  angina  •pectoris, 
may  occur  in  conjunction  with  fatty  degeneration.  No  special 
pathological  relation,  however,  exists  between  these  affections 
inasmuch  as  angina  pectoris  is  associated  with  other  organic  lesions 
of  the  heart.  Being  common  to  different  cardiac  affections,  I  shall 
treat  of  it  under  the  head  of  functional  disorders  of  the  heart. 

The  pathological  effects  of  fatty  growth  and  degeneration  are 
serious  in  proportion  as  they  involve  structural  change,  or,  in  other 
words,  atrophy  and  impaired  consistence  of  the  walls  of  the  heart. 

'  On  the  Diseases  of  the  Heart  and  Aorta,  Am.  ed.,  p.  340. 

2  Mr.  Edward  Canton,  of  London,  first  ascertained  that  the  arcus  senilis  is  due  to 
fatty  degeneration  of  the  cornea,  and  advocated  the  opinion  that,  when  present, 
under  the  age  of  40,  it  is  invariably  associated  with  fatty  heart,  vide  London  Lan- 
cet, 1850  and  1851.  As  regards  the  frequency  of  its  association  with  fatty  heart, 
clinical  experience  is  thus  far  discrepant.  Vide  Williams^  Principles  of  Medicine, 
and  article  by  Dr.  Hopkins,  in  Am.  Journ.  of  Med.  Sci.,  Jan.  1853.  Also  an 
Essay  "  On  the  Symptomatic  Value  of  the  Arcus  Senilis ;  with  a  tabulated  state- 
ment of  Seventy-two  Cases."  By  Benjamin  Lee,  A.  M.,  M.  D.,  in  the  Am.  Med. 
Month.,  Sept.  185G. 


FATTY  GROWTH  AND  DEGENERATION.  99 

Hence,  fatty  degeneration  is  the  form  of  disease  wLicli  is  especially 
attended  with  notable  disorder  and  danger.  The  atrophy  in  this 
affection  differs  from  that  previously  considered  under  the  head  of 
atrophy,  with  diminished  bulk  of  the  heart.  The  muscular  sub- 
stance lost  is  replaced  by  the  deposit  of  fat,  which  makes  good  the 
volume  of  the  heart,  but,  of  course,  without  supplying,  in  any  mea- 
sure, the  loss  as  regards  the  function  of  the  organ.  Cases,  how- 
ever, of  death  simply  from  fatty  degeneration  of  the  heart  must  be 
exceedingly  rare.  The  best  anatomical  specimens  of  the  disease 
are  obtained  from  bedridden  patients  of  an  advanced  age.  It  may 
prove  fatal,  by  leading  to  rupture.  Sudden  death,  in  some  cases, 
also  occurs  in  an  attack  of  syncope ;  the  cavities  becoming  over- 
loaded, and  the  walls  too  feeble  to  propel  the  blood,  the  move- 
ments of  the  organ  are  suddenly  arrested.  Exclusive  of  these 
instances,  which  are  extremely  infrequent,  a  fatal  i^esult  is  gene- 
rally not  due  directly  to  the  cardiac  affection,  but  to  the  concurrent 
effects  of  associated  or  superinduced  pathological  conditions.  This, 
however,  by  no  means  renders  the  existence  of  fatty  degeneration 
unimportant,  either  as  regards  diagnosis  or  treatment.  Dr.  Stokes 
has  suggested  that  the  presence  of  an  amount  of  structural  change, 
not  sufficient  to  give  rise  to  well-marked  symptoms  of  cardiac  dis- 
ease, may  serve  to  explain  the  disproportionate  feebleness  of  the 
circulation,  tendency  to  syncope,  and  the  intolerance  of  bloodlet- 
ting and  other  debilitating  measures,  which  are  sometimes  observed 
in  different  affections.  The  probability  of  the  coincidence  of  the 
affection  under  consideration,  is  to  be  taken  into  account  in  cases 
in  which  the  fact  cannot  be  positively  determined. 


Physical  Signs  and  Diagnosis  of  Fatty  Growth  and  Degeneration. 

The  accumulation  of  fat  is  very  rarely  sufficient  to  increase  the 
size  of  the  heart  much  beyond  the  limit  of  the  variations  in  health. 
If,  therefore,  percussion  show  a  considerable  amount  of  enlargement, 
dilatation  is  to  be  inferred.  Dilatation  and  fatty  disease  are  not 
unfrequently  combined,  and  the  question  at  once  arises,  is  the  diag- 
nosis of  the  latter,  under  these  circumstances,  practicable?  The 
extent  of  enlargement  of  the  heart  can  generally  be  determined  with 
precision.  By  means  of  percussion  and  palpation,  the  space  which 
the  organ  occupies  can  be  delineated  and  measured.  Now,  if  the 
enlargement  be  sufficient  in  extent  to  correspond  with  the  asso- 


100      LESIONS    AFFECTING    THE    WALLS    OF    THE    HEART. 

ciated  signs  and  symptoms,  evidence  of  fatty  disease  is  wanting; 
but  if,  on  the  contrary,  the  signs  and  symptoms  denote  a  degree  of 
cardiac  weakness  out  of  proportion  to  the  enlargement,  fatty  dis- 
ease may  be  strongly  suspected ;  and,  if  other  circumstances  are 
present  pointing  to  the  latter  disease,  the  diagnosis  may  frequently 
be  made  with  much  positiveness.  The  exclusion  of  valvular  lesions 
is  an  important  point  in  the  diagnosis.  If  valvular  lesions  are  not 
present,  the  coexistence  of  fatty  degeneration  is  rendered  highly 
probable  by  the  fact  of  dilatation,  the  latter  probably  occurring  in 
consequence  of  the  former.  It  is  to  be  borne  in  mind  that  the  pre- 
sence of  valvular  lesions  by  no  means  precludes  the  existence  of 
fatty  disease ;  but  in  cases  in  which  valvular  lesions,  enlargement 
and  fatty  disease  are  combined,  the  diagnosis  of  the  latter  cannot 
certainly  be  made  with  positiveness.  It  may,  however,  be  reason- 
ably suspected  when,  under  these  circumstances,  the  weakness  of 
the  heart  is  greater  than  would  be  expected  from  the  amount  of 
dilatation. 

Limiting  the  attention  to  cases  in  which  fatty  disease  is  the  sole 
or  paramount  lesion,  and  in  which  the  atrophic  changes  are  suffi- 
cient to  give  rise  to  well-marked  manifestations  of  a  cardiac  affec- 
tion, what  are  the  physical  signs  furnished  by  the  different  methods 
of  exploration  ?  Percussion  shows  moderate  or  no  increase  of  the 
volume  of  the  heart.  This  is  an  important  negative  point.  The 
apex-beat,  if  felt,  will  be  but  little,  if  at  all  removed  from  its  normal 
situation.  The  beat,  if  felt,  is  abnormally  feeble,  and  it  will  be  in- 
appreciable if  the  heart  be  greatly  weakened.  Impulses  elsewhere 
than  over  the  apex,  will,  in  general,  not  be  discoverable.  Inspec- 
tion may  disclose  a  very  feeble  movement  over  the  apex,  or  none 
whatever.  The  diminished  force  or  suppression  of  the  apex  beat 
will  depend,  of  course,  on  the  extent  to  which  the  left  ventricle  is 
affected.  The  sounds  of  the  heart  are  weakened.  The  first  sound, 
more  than  the  second,  shows  abnormal  weakness.  It  is  also  short 
and  valvular,  resembling,  in  these  respects,  the  second  sound.  The 
greater  weakness  of  the  first  sound  and  its  altered  quality,  are  due 
to  the  effect  upon  the  element  of  impulsion.  This  element  is  im- 
paired more  than  the  valvular  element,  and  may  be  suppressed 
while  the  latter  remains.  The  first  sound  may  be  wanting,  the 
second  sound  being  still  heard ;  and,  finally,  both  sounds  may  be 
extinct.  The  latter  obtains  in  cases  of  a  very  great  degree  of  fatty 
degeneration. 

When  in  connection  with  these  physical  signs,  there  are  present 


FATTY  GROWTH  AND  DEGENERATION.  101 

symptoms  denoting  a  cardiac  aff'ection,  viz:  feebleness,  and  perliaps 
irregularity  of  the  pulse;  palpitation  and  proecordial  distress;  dys- 
pno3a  on  exercise,  tendency  to  syncope,  etc.,  there  can  be  but  little 
room  for  doubt  that  the  heart  is  affected  with  fatty  degeneration, 
especially  if  the  patient  have  passed  the  middle  period  of  life,  if  his 
habits  of  life  have  been  luxurious  and  indolent,  if  he  have  been  ad- 
dicted to  alcoholic  beverages,  if  he  have  the  arcus  senilis,  or  if  there 
be  a  tendency  to  obesity.  The  diagnosis  is  not  difficult  under  these 
circumstances.  It  is  less  easy  when  the  problem  is  to  decide  whether 
fatty  degeneration  exists  in  addition  to  enlargement  and  valvular 
disease ;  and  also  when  the  amount  of  degeneration  is  not  suffi- 
ciently great  to  give  rise  to  well-marked  symptoms  and  signs  of 
cardiac  disease.  The  probability  of  the  coexistence  of  this  lesion 
with  other  affections  which  the  physician  is  called  upon  to  treat, 
is  important  to  be  taken  into  account  in  the  interpretation  of  symp- 
tomatic phenomena,  and  the  employment  of  therapeutical  measures. 


Treatment  op  Fatty  Growth  and  Degeneration. 

The  general  objects  of  medical  treatment  in  cases  of  fatt}''  growth 
and  degeneration  are  threefold,  viz.,  1.  To  obviate  and  relieve  the 
immediate  effects  of  weakness  of  the  heart ;  2.  To  increase  perma- 
nently the  muscular  power  of  the  organ;  and  3,  To  arrest  or  limit 
the  accumulation  of  fat. 

Of  the  immediate  effects  of  the  cardiac  weakness  incident  to  these 
affections,  the  more  prominent  are  palpitation  and  praecordial  dis- 
tress, syncope,  dyspnoea,  and,  possibly,  apoplectiform  coma.  These 
effects  occur  generally  in  parox^^sms,  induced  by  causes  which 
either  temporarily  increase  the  habitual  weakness,  or  which,  like 
exercise,  mental  excitement,  etc.,  overtask  the  power  of  the  heart. 
Some  of  the  effects,  however,  may  be  more  or  less  constant.  The 
means  of  obviating  and  relieving  them  consist  of  measures  to 
augment  the  force  of  the  ventricular  contractions ;  in  other  words, 
the  use  of  remedies  which  act  as  cardiac  stimulants.  These  are 
wine  or  spirits,  ether,  and  the  carbonate  of  ammonia.  They  are  to 
be  given  more  or  less  freely  according  to  the  urgency  of  the 
symptoms,  that  is,  in  proportion  to  the  degree  of  cardiac  weakness ; 
and  they  are  to  be  continued  or  repeated  according  to  the  persist- 
ence or  recurrence  of  the  paroxysms.  Their  habitual  use  is  indi- 
cated if  the  effects  are  constant.     The  particular  stimulants  to  be 


102       LESIONS    AFFECTING    THE   WALLS    OF    THE    HEART. 

selected  must  vary  with  reference  to  the  habits  of  patients  and  the 
results  of  ejxperience  in  individual  cases.  As  regards  quantity, 
thej^  are  to  be  graduated  by  the  symptoms  and  by  the  relief 
afforded.  It  is  impossible  to  formularize  the  means  of  fulfilling 
this  object  of  treatment.  Here,  as  well  as  with  reference  to  the 
other  objects  of  treatment,  with  a  clear  idea  of  the  ends  and  means, 
the  judicious  practitioner  will  not  be  at  a  loss  as  regards  therapeu- 
tical details.  Without  a  proper  knowledge  of  the  pathological 
character  of  the  immediate  effects,  serious  errors  of  practice  may  be 
committed.  Depletion  by  bloodletting  or  otherwise,  and  all  mea- 
sures tending  to  enfeeble  still  more  the  circulation,  can  hardlj^  fail 
to  be  pernicious.  In  the  attacks  of  pseudo-apoplexj^,  which  have 
been  referred  to,  whether  immediately  dependent  on  the  heart  or 
not,  stimulants  are  not  to  be  withheld  on  the  supposition  that  the 
brain  is  congested.  Cerebral  congestion,  it  is  to  be  borne  in  mind, 
may  proceed  from  enfeebled  power  of  the  heart.  In  employing 
diffusible  or  alcoholic  stimulants,  the  aim  is  not  to  excite  the  heart, 
but  to  strengthen  its  action.  If  they  produce  greater  frequency  of 
the  pulse,  the  end  is  not  attained.  Their  effect  should  be  augmented 
force  and  volume  of  the  pulse ;  and  with  this  effect  the  frequency 
may  be  diminished  and,  the  rhythm  become  more  regular.  Reme- 
dies to  retard  the  frequency  of  the  pulse,  such  as  digitalis,  are  of 
doubtful  utility.^  Revulsive  measures,  such  as  stimulating  pedi- 
luvia,  are  useful,  as  in  dilatation,  by  diverting  the  blood  from  the 
heart,  and  thus  diminishing,  for  the  time,  the  labor  of  the  circula- 
tion. These  remarks  apply  to  remedial  measures.  It  is  hardlj' 
necessary  to  say  that  all  the  causes  which  either  induce  temporarily 
the  habitual  weakness  or  overtask  the  power  of  the  heart  are,  as 
far  as  practicable,  to  be  avoided  and  removed.  Undue  ftitigue  or 
depressing  agencies  of  all  kinds,  physical  and  mental,  violent  mus- 
cular exertions,  excitement,  etc.,  belong  in  the  category  of  exciting 
causes. 

The  second  object,  viz.,  to  increase  permanently  the  muscular 

'  M.  Beau,  of  Paris,  contends  tliat  digitalis  not  only  diminished  the  frequency  of 
the  heart's  contractions,  but  that,  by  a  special  action,  it  imparts  to  them  increased 
strength  and  renders  them  more  complete.  To  quote  his  language  :  "  La  digitate 
est  un  tonique  sji^cial  chi  cuur ;  c^est,  a  vrai  dire,  le  quinquina  du  caur."  (Traite  Ex- 
perimental et  Clinique  d' Auscultation,  etc.,  1856,  p.  372.)  He  states  that  this 
opinion  vras  held  by  Saunders.  If  the  opinion  be  correct,  so  far  from  being  contra- 
indicated,  the  remedy  is  peculiarly  adapted  to  the  treatment  of  the  affections  under 
consideration,  as  well  as  cases  of  dilatation.  I  am  not  prepared  to  express  either 
assent  or  denial,  but  there  seems  to  me  some  foundation  for  the  opinion. 


TREATMENT  OF  FATTY  GROWTH  AND  DEGENERATION.      103 

power  of  the  heart,  is  to  be  effected  by  tonic  remedies,  by  an 
appropriate  system  of  diet  and  regimen,  and  by  judiciously  ]-egu- 
lated  exercise.  Tonic  remedies  are  called  for  with  a  view  to 
improvement  of  the  appetite  and  digestion,  if  impaired  or  dis- 
ordered, Quinia,  bitter  infusions,  and  the  mineral  acids,  are  often 
useful  with  reference  to  this  end.  The  preparations  of  iron  are 
especially  indicated  if  anasmia  exist.  An  anasmic  condition  is  to 
be  dreaded  not  less  in  these  than  in  other  affections  of  the  heart; 
in  all,  the  symptoms  are  greatly  aggravated  whenever  it  coexists. 
Flatulency  and  constipation  are  to  be  relieved  by  suitable  remedies. 
With  reference  to  the  proper  performance  of  the  digestive  functions, 
wine,  spirits,  or  beer,  in  moderate  quantity,  may  generally  be  taken 
with  advantage.  The  dietetic  course  is  of  very  great  importance. 
The  end  is  to  contribute  towards  tbe  healthy  nutrition  of  the 
affected  organ  by  rendering  the  blood  rich  in  nutritive  materials. 
For  this  end,  the  articles  of  diet  should  be  highly  nutritious  and 
easily  assimilated.  The  diet  should  consist  of  as  large  a  proportion 
of  animal  food  as  the  digestive  powers  will  permit.  The  quantity 
of  fluids  should  be  restricted,  in  order  that,  while  the  blood  is 
enriched  in  quality,  the  vessels  and  heart  cavities  shall  not  be 
unduly  repleted,  the  labor  of  carrying  on  the  circulation  being- 
proportionate  to  the  mass  of  liquid  to  be  circulated.  Warm  cloth- 
ing is  of  importance  to  secure  the  distribution  of  a  proper  propor- 
tion of  blood  to  the  surface  and  extremities.  Excesses  of  all  kinds, 
in  eating,  drinking,  venery,  mental  occupation  or  excitement,  late 
hours,  etc.,  are  to  be  rigidly  interdicted,  Eegular  habits  of  life  in 
all  respects  are  important.  Judiciously  regulated  exercise  in  the 
open  air  constitutes  a  part  of  the  management  not  least  in  import- 
ance. Physical  indolence  predisposes  to  these  affections ;  and,  on 
the  other  hand,  by  habitual,  systematic  exercise,  the  heart  is 
directly  strengthened.  Great  caution,  however,  is  to  be  observed 
in  this  part  of  the  management.  While  judiciously  regulated 
exercise  is  of  great  importance,  injudicious  excess  may  do  much 
harm.  The  practical  rule  to  be  observed  here  is  the  same  as  in 
cases  of  dilatation.  The  patient  is  to  be  encouraged  to  take  such 
exercise  as  he  is  able  without  experiencing  inconvenience  from 
dyspnoea  or  palpitation;  in  other  words,  undue  excitation  of  the 
action  of  the  heart  is  to  be  the  limit.  As  the  ability  to  endure 
greater  and  more  prolonged  exercise  augments,  the  limit  may  be 
enlarged  and  extended.  Violent  exertions  are  never  appropriate ; 
walking,  riding,  rowing,  the  use  of  dumb-bells,  etc.,  should  be  the 


104      LESIONS    AFFECTING    THE    WALLS    OF    THE    HEAET. 

modes  of  exercise  resorted  to.  Pedestrian  and  equestrian  excur- 
sions, involving  the  mental  interest  of  travelling,  and  hunting,  and 
llshing,  if  pursued  with  zest,  are  especially  to  be  recommended. 
Proper  instruction  and  cautions  are  to  be  enjoined,  as  the  tendency 
with  many  persons  is,  when  once  a  system  of  exercise  is  under- 
taken, to  push  it  to  an  extreme.  The  reader  will  have  observed 
that  thus  far  the  principles  of  management  do  not  differ  materially 
from  those  to  be  pursued  in  cases  of  dilatation  of  the  heart.  The 
ends  of  management  in  dilatation  and  in  fatty  degeneration  are,  in 
fact,  the  same.  The  two  lesions  are  often  combined,  and  in  treating 
the  latter,  an  incidental  object  is  to  endeavor  to  prevent  or  limit 
the  former. 

The  third  object,  viz :  to  arrest  or  limit  the  fatty  accumulation, 
is  peculiar  to  the  aSections  under  consideration.  Theoretically 
considered,  this  object  more  clearly  relates  to  fatty  growth  than  to 
fatt}''  degeneration.  The  former,  in  general,  involves  a  tendency  to 
the  accumulation  of  fat  in  different  parts  of  the  body,  or  the  adipose 
diathesis.  The  latter  does  not  so  generally  involve  this  tendency 
or  diathesis.  That  it  does  so  to  a  greater  or  less  extent  is,  however, 
probable.  In  fact,  fatty  growth  and  degeneration  are  often  asso- 
ciated. The  constitutional  disposition,  or,  to  speak  more  properly, 
the  state  of  the  blood  favorable  to  obesity,  may  be  controlled  in  a 
great  degree  by  a  diet  adapted  to  this  end,  conjoined  with  habits  of 
exercise.  Fatty  and  saccharine  substances  should  be  interdicted, 
and  articles  abounding  in  amylaceous  principles  are  to  be  sparingly 
allowed.  The  diet  should  consist  of  meat,  bread,  non-farinaceous 
vegetables,  and  certain  kinds  of  fruit.  Vegetables  which  are  highly 
farinaceous,  such  as  potatoes  and  rice,  should  be  taken  sparingly. 
By  following  this  plan  with  perseverance,  I  have  known  an  exces- 
sive corpulence  greatly  reduced,  and  the  general  health  much  im- 
proved. Caution  is  here  necessary,  lest  the  dietetic  course  be 
pushed  to  an  extreme.  The  powers  of  the  system  are  by  no  means 
to  be  lowered.  A  proper  variety  of  alimentary  principles  is  to  be 
provided.  It  is  only  necessary  that  fatty  substances  be  interdicted, 
and  that  those  principles  readily  transformed  into  fat,  viz  :  sugar 
and  starch,  constitute,  relatively,  a  small  proportion  of  the  articles 
of  diet.^     Habits  of  exercise,  it  is  well  known,  tend  to  prevent  the 

'  A  late  writer,  Dr.  Markliam,  sajs  :  "I  believe  I  have  seen  cod-liver  oil,  com- 
bined with  steel,  followed  by  very  satisfactory  results  in  supposed  cases  of  fatty 
degeneration  of  tlie  heart."  (Diseases  of  the  Heart,  London,  1856,  p.  289.) 

It  should  be  clear  that  the  results  were  due  to  the  oil,  and  not  to  the  steel  and 


TEEATMENT  OF  FATTY  GROWTH  AXD  DEGENERATION.   105 

accumulation  of  fat.  In  this  point  of  view,  ihej  are  useful,  in  ad- 
dition to  their  more  direct  effect,  in  increasing  permanently  the 
muscular  power  of  the  organ.  Dr.  Stokes  thinks  that  exercise 
during  summer  or  in  a  warm  climate,  when  it  is  attended  by  copious 
perspiration,  is  especially  useful,  fatty  principles  being  eliminated, 
in  considerable  quantity  from  the  surface. 

As  regards  the  success  of  treatment,  so  far  as  atrophy  or  degene- 
ration of  structure  has  taken  place,  the  lesion  must  be  considered 
as  incurable.  It  is  not  probable  that  the  substance  which  has  dis- 
appeared is  reproduced.  But  the  heart,  like  the  other  important 
organs  of  the  body,  may  sustain  a  certain  amount  of  damage,  while 
there  still  remain  sufficient  healthy  tissue  and  functional  power  for 
life  and  health;  and  although  that  which  is  actually  lost  in  struc- 
ture cannot  be  recovered,  the  deficiency  may  be  made  up  by  in- 
creasing the  development  and  vigorous  action  of  the  normal  tissue 
which  remains.  Thus,  a  heart  more  or  less  unsound  from  fatty 
degeneration,  may  perhaps  be  rendered  more  efficient  than  it  was 
even  before  the  degeneration  commenced.  This  statement  is,  of 
course,  not  applicable  when  the  unsoundness  is  considerable.  But 
assuming  that  a  certain  degree  of  weakness  is  inevitable  for  the 
remainder  of  life,  if  the  progress  of  the  structural  affection  can  be 
stayed,  and  the  capabilities  of  the  organ  developed  and  maintained, 
the  condition  of  the  patient  may  not  be  serious  even  with  a  con- 
siderable amount  of  unsoundness.  With  this  view  of  the  subject, 
the  importance  of  an  early  diagnosis  is  sufficiently  obvious. 

The  importance  of  recognizing  fatty  disease  of  heart  in  connec- 
tion with  inflammatory  diseases  affecting  other  organs,  is  not  to  be 
lost  sight  of.  If  there  be  grounds  for  suspecting  the  coexistence  of 
fatty  growth  and  more  especially  fatty  degeneration,  depletion  and 
debilitating  measures  are  to  be  emploj^ed  with  great  circumspection. 
The  question  as  to  the  presence  of  these  affections  will,  in  fact, 
oftener  arise  in  such  a  connection,  than  in  cases  in  which  attention 
is  called  to  a  cardiac  disease  exclusively. 

In  conclusion,  the  subject  of  fatty  degeneration  of  the  heart  offers 
a  field  for  farther  anatomical  researches,  especially  by  means  of  the 
microscope,  and  also  for  clinical  observation,  with  a  view  to  the 
development  of  facts  which  may  be  expected  to  shed  light  on  its 
pathology,  diagnosis  and  treatment. 

other  measures  ;  and,  also,  that  the  disease  was  fatty  degeneration,  in  order  to 
base  thereon  the  propriety  of  this  remedy. 


106      LESIONS    AFFECTING    THE    WALLS    OF    THE    HEART. 


SOFTENING    OF    THE    HEART. 


Softening  of  the  heart  has  been  already  considered  as  incidental 
to  fatty  degeneration.  It  will  be  noticed  in  a  future  chapter  as  a 
result  of  inflammation.  Exclusive  of  these  pathological  connec- 
tions, it  belono's  among  the  anatomical  changes  which  are  liable  to 
take  place  in  the  course  of  the  essential  fevers,  especially  typhoid 
fever  and  typhus.  Its  occurrence  in  typhoid  fever  was  observed 
by  Laennec ;  but  it  was  more  fully  studied  by  Louis,  in  those  re- 
searches which  established  the  natural  history  of  that  disease.  In 
a  certain  proportion  of  cases  of  typhoid  fever  ending  fatally,  Louis 
found  the  muscular  walls  of  the  heart  more  or  less  softened.  Some- 
times the  softening  was  limited  to  the  left  ventricle  and  sometimes 
it  extended  over  both  ventricles.  When  the  diminished  consistence 
was  marked,  the  walls  were  notably  relaxed  and  friable.  The  struc- 
ture Avas  easily  torn  and  penetrated  with  the  finger ;  the  organ  was 
flaccid,  collapsing  by  its  own  weight,  and  not  preserving  its  natural 
form,  but  retaining,  like  a  wet  cloth,  any  shape  in  which  it  was 
placed.  When  incised,  the  cut  surfaces  were  dry  and  unpolished, 
and  the  color  of  the  muscular  tissue  was  purplish  or  livid.  These 
alterations  were  not  accompanied  by  any  marked  change  in  volume, 
nor  by  any  of  the  products  of  inflammation.' 

Softening  of  the  heart,  as  occurring  both  in  typhoid  and  typhus 
fever,  has  also  been  studied  with  much  care  by  Dr.  Stokes,  his  ob- 
servations agreeing  in  all  important  particulars  with  those  of  Louis. 
Dr.  Stokes  has  observed  instances  in  which  the  external  muscular 
layer  of  the  left  ventricle  appeared  to  be  converted  into  a  homo- 
geneous substance,  all  traces  of  muscular  fibre  being  lost.  He  has 
also  remarked  an  adhesive  gummy  liquid,  with  which  the  affected 
muscular  substance  was  infiltrated.^ 

The  softening,  under  these  circumstances,  is  evidently  due  to  a 
process  which  may  be  called  acute,  for  it  occurs  early  in  the  disease, 
and  is  most  frequent  and  marked  in  the  bodies  of  those  who  have 
died  after  a  short  career  of  the  fever.     Examinations  made  soon 

'  Vide  Anatomical,  Pathological,  and  Therapeutic  Researches  upon  the  Disease 
known  under  the  Name  of  Gastro-enterite,  etc.  Translated  by  H.  J.  Bowditch 
M.  D.,  1886,  vol.  1. 

^  Stokes  on  Diseases  of  the  Heart  and  Aorta.     Am.  ed.,  p.  388. 


SOFTENING  OF  THE  HEART.  107 

after  death,  show  that  it  is  not  due  to  cadaveric  decomposltiou  witli 
which,  without  proper  care,  it  is  liable  to  be  confounded.  It  may 
be  associated  with  softening  of  other  viscera — especially  of  the  liver 
and  spleen — but  the  voluntary  muscles  are  not  found  to  have  un- 
dergone a  similar  change. 

Of  its  pathological  character  and  the  mechanism  of  its  produc- 
tion, all  that  can  be  said,  with  our  present  knowledge,  is,  tliat  it  is 
one  of  the  secondary  lesions  dependent  on  the  unknown  morbid 
conditions  which  constitute  the  essential  fevers.  Whether  the  pro- 
cess involves,  primarily,  molecular  changes  due  either  to  a  morbid 
state  of  the  blood,  or  to  abnormal  innervation;  or  whether  the  first 
step  is  the  infiltration  of  a  liquid  which  acts  on  the  muscular  tissue, 
remains  to  be  ascertained.  At  present,  the  points  important  to  be 
borne  in  mind  with  reference  to  their  practical  bearings  are,  its 
dependence  on  the  essential  pathological  conditions  in  fever,  what- 
ever they  may  be,  and  its  non-inflammatory  character.  That  it 
produces,  in  certain  cases,  a  degree  of  weakness  of  the  heart,  which 
renders  the  occurrence  of  the  lesion  an  important  event  in  the  pro- 
gress of  the  disease,  contributing  not  unfrequently,  to  a  fatal  result, 
is  not  to  be  doubted.  Clinical  observation,  however,  furnishes  evi- 
dence that  it  is  a  lesion  which  often  occurs  without  leading  to 
serious  consequences,  and  that  it  admits  of  rapid  and  complete 
restoration.  There  is  no  ground  for  the  supposition  that  it  lays 
the  foundation  for  permanent  organic  disease  of  the  heart. 

Softening  of  the  heart,  analogous  to  that  just  described,  is  not 
peculiar  to  the  tjqihus  and  typhoid  fevers.  It  may  occur  in  other 
essential  fevers.  It  has  also  been  observed  in  purulent  infection  of 
the  blood,  in  scorbutus,  purpura,  and  other  affections.  As  an  ele- 
ment in  the  history  of  other  diseases  than  the  continued  fevers,  it 
has  been  less  studied.  Except  as  a  secondary  lesion  developed 
during  the  progress  of  some  general  disease,  it  probably  rarely,  if 
ever,  occurs  independently  of  fatty  degeneration  or  inflammation. 
But  with  reference  to  this  point,  as  well  as  to  the  frequency  of  its 
occurrence  in  various  diseases,  further  researches,  with  the  aid  of 
]nicroscopical  observation,  are  desirable.  The  microscope  has  been 
of  great  service  in  determining  the  dependence  of  softening  on  fatty 
degeneration  in  a  large  proportion  of  the  instances  in  which  it  is 
observed  after  death. 

The  symptoms  and  pathological  effects  of  softening  of  the  heart 
are  essentially  the  same  as  in  fatty  degeneration.  They  proceed 
from   v/cakness   of  the   orcran,  and   are   commensurate,  as   regards 


103       LESIONS    AFFECTING    THE    WALLS    OF    THE    HEAET. 

their  intensity,  with  the  loss  of  muscular  power  incident  to  the 
lesions.  There  is  this  vast  difference,  however,  in  the  two  forms  of 
disease,  viz.,  the  weakness  due  to  fatty  degeneration  is  permanent, 
while  that  incident  to  softening  in  fever  is  temporary,  the  lesion  in 
the  one  case  being  incurable,  and  in  the  other  case  recovery  taking 
place  with  certainty  and  rapidity,  provided  the  fever  end  in  con- 
valescence. The  pulse,  in  both  cases,  represents  but  imperfectly 
the  degree  of  cardiac  weakness.  Other  circumstances  belonging  to 
the  circulation  than  the  systole  of  the  left  ventricle  affect  materially 
the  qualities  of  the  pulse,  especially  the  amount  of  resistance  offered 
to  the  passage  of  blood  through  the  capillary  vessels  from  failure 
of  the  forces  presiding  over  the  circulation  in  these  vessels,  irre- 
spective of  the  vis  a  tergo  derived  from  the  heart.  On  the  other 
hand,  feebleness  of  the  pulse  may  proceed  from  other  causes  than 
softening  of  the  heart,  and,  therefore,  when  strongly  marked,  it  is 
by  no  means  distinctive  of  this  lesion.  In  cases  of  fever,  moreover, 
the  sj'mptoms  and  pathological  effects  of  cardiac  softening  are  so 
intermingled  with  the  phenomena  pertaining  to  the  febrile  disease 
that  it  is  impossible  to  isolate  them.  Functional  weakness  of  the 
heart,  without  softening,  is  sufficiently  common  in  typhus  and 
typhoid  fever,  and  the  feebleness  of  the  circulation,  particularly  as 
denoted  by  the  pulse,  may  be  as  great  in  the  one  case  as  in  the 
other.  The  diagnosis  of  softening,  in  short,  cannot  always  be  made 
with  positiveness.  Still,  with  the  aid  of  physical  signs  and  atten- 
tion to  certain  points,  the  occurrence  of  this  lesion  may  be  deter- 
mined, in  some  cases,  with  considerable  confidence.  It  suffices  for 
all  practical  purposes  to  consider  the  physical  signs  and  diagnosis 
of  softening  as  occurring  in  typhus  and  typhoid  fever.  The  same 
considerations  are  applicable  to  the  lesion  when  it  takes  place  in 
other  pathological  connections  in  which  it  has  not,  as  yet,  been  so 
fully  investigated. 

The  physical  signs  of  softening  of  the  heart  in  fever  were  first 
thoroughly  studied  and  their  importance  enforced  by  Dr.  Stokes.' 
The  signs  are  essentially  those  which  belong  to  fatty  degeneration, 
but,  at  the  time  of  the  original  observations  by  Dr.  Stokes,  the 
latter  affection  was  very  imperfectly  understood.  To  recapitulate 
these  signs  in  the  present  connection,  the  apex-impulse  becomes 

•  Dr.  Stokes's  original  observations  were  made  in  1837  and  1838,  and  published 
shortly  afterwards.  But  the  reader  is  referred  to  his  late  work  on  Diseases  of  the 
Heart  and  Aorta  for  a  full  consideration  of  the  subject. 


SOFTENING  OF  THE  HEART.  109 

notably  feeble  or  is  suppressed;   the  intensity  of  both  sounds  is 
diminished,  but  the  first  sound  is  relatively  much  more  weakened 
than  the  second.     The  first  sound  is  altered  in  quality  and  dura- 
tion, becoming  short  and  valvular,  in  these  respects  resembling  the 
second    sound ;    in  other  words,  it  loses  those  characters  which 
belong  to  the  element  of  impulsion,  and  is  analogous  to  the  sound 
of  the  foetal  heart.     These  abnormal  changes  may  be  more  or  less 
strongly  marked.    The  first  sound  is  sometimes  extinguished,  while 
the  second  sound  continues  to  be  heard,  and  in  some  instances  both 
sounds  are  inappreciable.     The  latter  indicates  great  debility  of  the 
heart,  and  is  very  rarely  observed.     Taking  place  in  the  second 
week  of  the  career  of  typhus  or  typhoid  fever,  when,  during  the 
early  period  of  the  disease,  the  impulse  and  sounds  had  been  suffi- 
ciently intense,  and  had   presented  their  normal  characters,  these 
signs  denote  either  softening  or  simply  functional  weakness  of  the 
heart.     Therapeutically,  the  indications  are  the  same  whether  they 
are  due  to  softening  or  to  functional  weakness,  and,  in  a  practical 
point  of  view,  it  is  not  of  great  importance  to  make  the  discrimina- 
tion.    As  a  matter  of  scientific  interest,  however,  the  differential 
diagnosis  is  deserving  of  attention.     AVhat,  then,  are  the  points 
which   indicate  softening;?     The  researches  of  Louis  show  that 
softening  is  apt  to  occur  rather  early  in  the  febrile  career,  at  or 
soon  after  the  end  of  the  first  week.     Functional  weakness,  suffi- 
cient to  give  rise  to  the  abnormal  modifications  of  the  sounds  and 
impulse  which  have  been  described,  is  not  likely  to  occur  until  a 
later  period.     If,  therefore,  the  signs  are  present  early,  the  pre- 
sumption is  in  favor  of  softening.     Functional  weakness  will  be 
likely  to  be  associated  with  marked  general  debility  of  the  muscu- 
lar system.     It  occurs  in  cases  characterized  by  adynamia.     Soft- 
ening, being  a  special  lesion,  may  take  place  when  the  voluntary 
muscles  do  not  manifest  extreme  prostration.    Want  of  correspond- 
ence, therefore,  between  the  evidences  of  cardiac  weakness  and  the 
condition  of  the  general  muscular  system  points  to  softening.     Dr. 
Stokes  attaches  significance  to  the  slow  development  of  softening. 
The  signs  of  the  cardiac  weakness,  due  to  this  lesion,  are  observed 
to  become  progressively  but  gradually  marked,  and  then  for  some 
time  steadily  persist,  while  functional  debility  is  liable  to  be  rapidh^ 
induced,  to  vary  from  day  to  day,  and  is  often  less  persistent,     A 
point  more  distinctive  than  any  other,  which  is  available  in  a 
certain  proportion  of  cases,  relates  to  the  results  of  a  comparison  of 
the  heart-sounds  in  different  situations  within  the  pra^cordia.     It 


110      LESIOXS    AFFECTING   THE    WALLS    OF    THE    HEART. 

has  been  already  stated  that  the  softening  is  limited  to  or  especially 
marked  in  the  left  ventricle.  Kow,  as  stated  by  Dr.  Stokes,  under 
these  circumstances,  the  first  sound  may  be  loader  at  the  inferior 
border  of  the  heart,  where  it  is  derived  from  the  action  of  the  right 
ventricle,  than  over  the  left  ventricle.  This  shows  that  the  muscu- 
lar power  of  the  latter  is  diminished  more  than  that  of  the  former, 
a  fact  which  is  highly  significant  of  softening,  because  the  causes 
inducing  merely  functional  weakness  are  alike  operative  on  the 
two  ventricles,^  Finall}',  the  reduction  of  the  pulse  in  frequency 
below  the  normal  average,  which  is  observed  at  the  time  of  con- 
valescence, in  a  certain  proportion  of  cases  of  tj^phus  and  typhoid 
fever,  is  supposed  by  Dr.  Stokes  to  denote  that  softening  has  taken 
place. 


Treatment  of  Softening  of  the  Heart. 

The  occurrence  of  softening  of  the  heart  in  the  coarse  of  typhus 
and  typhoid  fever  furnishes  an  additional  indication  for  sustaining 
measures,  viz :  diffusible  or  alcoholic  stimulants,  and  concentrated 
nutriment.  The  tendency  to  death  by  asthenia  is  enhanced  by  the 
complication  of  this  lesion,  and,  hence,  the  means  of  obviating  this 
tendency  are  to  be  pushed  with  more  vigor  whenever  there  are 
reasonable  grounds  for  supposing  that  the  lesion  has  taken  place. 
These  remarks  are  equally  applicable  to  the  treatment  of  softening 
when  it  occurs  in  other  pathological  connections,  as  in  the  eruptive 
fevers,  pj-emia,  &c.  Dr.  Stokes  has  called  attention  to  the  import- 
ance of  the  physical  signs  of  cardiac  weakness  in  determining  the 
extent  to  which  sustaining  measures,  and  especially  alcoholic 
stimulants,  are  indicated  in  the  treatment  of  fevers.  The  dimin- 
ished intensity  or  suppression  of  the  first  sound  of  the  heart,  to- 
gether with  its  alterations  in  duration  and  quality,  constitute  a 
better  criterion  of  the  loss  of  muscular  power  which  the  organ  has 
sustained,  than  the  pulse  or  other  symptoms.  In  fact,  the  pulse,  as 
stated  already,  does  not  always  represent  fairly  the  force  with 
which  the  left  ventricle  contracts.  The  evidence  obtained  by  aus- 
cultation and  palpation  is  more  reliable.  With  reference  to  this 
end,  physical  exploration  practised  from   day  to  day  during  the 

'  It  may  be  conjectured  that  wlien  softening  is  limited  to  or  especially  marked 
in  the  left  ventricle,  the  pulmonary  second  sound  will  be  more  intense  than  the 
aortic.     This  is  a  point  to  be  settled  by  clinical  observation. 


INDUEATION  OF  THE  HEAET.  Ill 

febrile  career,  is  of  great  practical  value,  and  is  too  mucli  neglected 
by  medical  practitioners.  In  endeavoring  to  decide  between  soft- 
ening and  functional  debility  of  the  heart,  there  maybe  often  room 
for  doubt,  but,  happily,  so  far  as  relates  to  treatment,  the  indications 
are  the  same  in  both  cases,  and,  consequently,  no  harm  results  from 
error  in  this  differential  diagnosis.  Practicall}'',  the  important  end 
is  to  estimate  correctly,  by  means  of  the  physical  signs,  the  degree 
of  cardiac  weakness. 


INDURATION    OF    THE    HEART. 


Induration  of  the  muscular  walls  of  the  heart,  sufficient  to  con- 
stitute in  itself  a  lesion  or  an  important  element  of  organic  disease, 
is  extremely  rare.  Pathologically  it  involves  difi'erent  conditions. 
The  muscular  tissue  appears  to  be  capable  of  becoming  condensed 
in  a  remarkable  degree  without  obvious  disorganization  or  morbid 
deposit.  An  instance  was  described  by  Corvisart  in  which  the 
heart,  when  struck,  sounded  like  a  dice-box  or  hollow  horn  vessel, 
and  yet  the  natural  appearance  of  the  muscular  substance  was  pre- 
served. The  microscope  had  not  then  been  brought  to  bear  on  the 
study  of  minute  anatomy.  Portions  of  the  walls  present  sometimes 
the  firmness  and  appearance  of  cartilage.  This  must  "proceed  either 
from  exudation  due  to  an  imflammatory  process,  or  from  hyper- 
trophy of  the  cardiac  fascia,  described  by  Dr.  Robert  Lee,'  whicli 
forms  a  sheath  around  the  arteries,  veins,  and  nerves  contained 
within  the  substance  of  the  heart.  Calcareous  deposit  sometimes 
exists  between  the  muscular  fibres,  here  as  elsewhere  due  to  the 
metamorphosis  of  exudation  matter.  In  a  case  described  by  Burns, 
the  ventricles  were  said  to  be  so  completely  ossified  as  to  resemble 
the  bones  of  the  cranium.  Some  allowance  is  doubtless  to  be  made 
for  exaggeration  in  this  comparison.  These  conditions  probably 
belong  among  the  results  of  inflammation.  In  a  practical  point  of 
view,  induration  of  the  cardiac  walls  claims  only  a  passing  notice. 
Not  only  is  it  extremely  rare,  but  it  is  wanting  in  distinctive  signs 
and  symptoms.     The  diagnosis  is  impossible.     It  may  be  stated  as 

'  Philosophical  Transactions,  1848.      Vide  Bellingham  on  Diseases  of  the  Heart, 
part  i.,  Dublin,  1853,  p.  24. 


. 


112       LESIONS    AFFECTING    THE    WALLS    OF    THE    HEAET. 

a  rule  applicable,  at  least,  to  diseases  of  the  heart,  that  the  difficulty 
of  diagnosis  is  inversely  in  proportion  to  its  practical  importance. 
This  lesion  affords  an  illustration  of  the  rule.  Induration  proceed- 
ing from  either  of  the  conditions  mentioned,  is  irremediable.  It 
was  conjectured  by  Laennec  that  the  heart-sounds  would  be  in- 
tensified by  an  indurated  state  of  the  walls,  so  as  to  be  heard  at  a 
distance  from  the  chest  in  some  cases.  Clinical  observation,  how- 
ever, has  shown,  on  the  contrary,  that  the  sounds  are  enfeebled. 
This  would  be  expected  in  view  of  our  present  knowledge  of  the 
mechanism  of  the  sounds. 


CARDIAC    ANEURISM. 


The  term  aneurism  was  formerly  applied  to  enlargement  of  one 
or  more  of  the  compartments  of  the  heart,  due  either  to  hypertrophy 
or  dilatation.  This  application  of  the  term  is  manifestly  inappro- 
priate, and  is  now  discontinued  by  most  writers.  Cardiac  aneurism 
is  properly  a  circumscribed  or  pouch-like  dilatation  occurring  in 
one  or  more  of  the  anatomical  divisions  of  the  organ.  In  the  great 
majority  of  instances  it  is  seated  in  the  left  ventricle.  It  does  not 
occur  in  the  right  ventricle,  but,  in  a  very  small  proportion  of  cases, 
it  has  been  observed  in  the  left  auricle.  It  is  an  extremely  rare 
lesion,  yet  Mr.  Tburman  was  able  to  collect  for  analysis,  from 
various  sources,  accounts  of  seventy-four  cases.'  The  aneurismal 
dilatation  forms  a  tumor  varying  in  size  in  different  cases  from  that 
of  a  small  nut  to  a  sac  as  large  as  the  heart  itself.  It  contains 
layers  of  condensed  fibrin  and  various  forms  of  coagula,  like  arterial 
aneurisms.  It  is  sometimes  lined  or  studded  with  calcareous  mat- 
ter. It  occurs  in  the  great  majority  of  cases  at  the  apex,  but  it  may 
be  situated  at  any  point  on  the  anterior  or  posterior  surfaces  of  the 
ventricle,  and  on  the  inter-ventricular  septum.  The  cavity  of  the 
sac  communicates  with  the  ventricular  cavity  by  an  aperture  vary- 
ing in  different  cases  as  respects  form  and  size,  being  sometimes 

'  Mr.  Thurman's  paper  was  published  in  the  Medico-Chirurg.  Transactions, 
London,  vol.  xxi.,  1838.  The  reader  will  find  an  abstract  of  it  in  Hope's  Treatise 
on  Diseases  of  the  Heart,  etc.,  Am.  ed.,  1842,  p.  313.  Also  in  Bellingham  on  Dis- 
eases of  the  Heart,  part  ii.,  1857.  In  the  latter,  the  reader  will  find  copious 
references  to  the  literature  of  the  subject. 


CARDIAC    ANEURISM.  113 

direct  and  in  some  cases  sinuous.  The  walls  of  the  sac,  in  some 
cases,  include  the  endocardial  and  pericardial  membranes  unbroken, 
the  muscular  substance  having  mostly  or  quite  disappeared;  or 
there  has  occurred  solution  of  continuity  of  the  endocardial  mem- 
brane. In  the  latter  case,  according  to  Eokitansky,  the  aneurism 
may  be  considered  as  an  acute,  and  in  the  former  as  a  chronic  affec- 
tion. When  the  endocardial  membrane  is  perforated,  the  lesion 
probably  commenced  by  disease  of  this  membrane,  the  other  tissues 
undergoing  dilatation  from  the  pressure  of  the  blood.  This  is 
analogous  to  the  false  aneurism  of  surgical  writers.  The  tumor, 
under  these  circumstances,  does  not  attain  to  a  great  size.  In 
chronic  cases,  without  perforation  of  the  endocardium,  the  walls  of 
the  heart  yield  to  the  pressure  of  blood  and  become  dilated  in  con- 
sequence of  a  morbid  condition  at  the  part  affected.  This  condition 
generally  results  from  circumscribed  inflammation,  and  consists  of 
softening,  or  the  substitution  of  new  structure  for  the  muscular 
tissue.  The  affection,  when  thus  induced,  is  analogous  to  the  true 
aneurism  of  surgical  writers.  It  is  supposed  that  a  circumscribed 
abscess  of  the  walls  of  the  heart,  opening  into  the  cavity  of  the 
ventricle,  may  lead  to  aneurism.  This  is  a  very  brief  synopsis  of 
the  views  held  by  pathologists  concerning  the  formation  of  cardiac 
aneurism.  For  a  fuller  consideration  of  the  subject,  the  reader  is 
referred  to  works  on  morbid  anatomy.^  Two  or  more  aneurismal 
tumors  are  sometimes  present  in  the  same  case.  The  affection 
occurs  much  oftener  in  the  male  than  in  the  female. 

Cardiac  aneurism  may  be  associated  with  enlargement  of  the 
heart  by  hypertrophy  or  dilatation,  and  with  valvular  lesions,  but 
these  affections  do  not  uniformly  exist,  although  present  in  a  large 
proportion  of  cases.  In  the  cases  analyzed  by  Mr.  Thurman,  val- 
vular lesions  coexisted  in  ten,  and  were  stated  not  to  exist  in  eight, 
the  whole  number  of  cases  of  aneurism  of  the  left  ventricle  being 
fifty-eight.  In  ten  eases  only  of  the  whole  number,  i.  e.,  of  fifty- 
eight,  was  the  absence  of  hypertrophy  or  dilatation  stated.  Adhe- 
sion of  the  pericardial  surfaces  over  the  tumor  takes  place  in  some 
instances,  and  is  wanting  in  others.  Aneurismal  dilatation  of  the 
mitral  valve  will  be  more  properly  noticed  under  the.  head  of  val- 
vular lesions. 

Aneurism  of  the  heart  may  end  in  rupture  and  sudden  death, 

'  Rokitansky  treats  of  this  subject  at  considerable  length.  An  abridgment  of 
Rokitansky's  views  is  contained  in  the  work  by  .Jones  and  Sieveking. 

8 


114      LESIONS    AFFECTING    THE    AVALLS    OF    THE    HEAET. 

the  blood  being  poured  into  the  pericardial  sac,  provided  adhesion 
of  the  free  surfaces  of  the  pericardium  have  not  taken  place,  and, 
if  so,  the  opening  may  take  place  into  the  left  pleural  cavity.  But, 
prior  to  the  occurrence  of  this  event,  a  fatal  result  may  take  place 
in  consequence  of  the  embarrassment  of  the  circulation  occasioned 
by  the  tumor,  and  by  the  concomitant  lesions  with  which  it  is 
generally  associated. 

The  existence  of  this  affection  is  not  determinable  during  life. 
In  no  case  as  yet  observed,  has  the  diagnosis  been  made,  nor  is  it 
probable  that  any  diagnostic  criteria  will  be  ascertained  by  farther 
clinical  observation.  The  symptoms  in  the  cases  which  have  been 
reported,  are  those  denoting  some  grave  cardiac  affection,  but  they 
are  generally  due,  in  a  great  measure,  to  coexisting  valvular  lesions 
or  enlargement,  or  to  both.  Nor  are  the  physical  signs  more  dis- 
tinctive. The  passage  of  blood  currents  into  and  from  the  sac,  is 
likely  to  give  rise  to  a  murmur,  which  may  accompany  either 
sound  of  the  heart,  or  both  sounds.  A  friction  murmur  may  also 
be  produced.  But  there  are  no  circumstances  which  can  possibly 
lead  the  diagnostician  to  pronounce  that  these  signs  are  due  to  an 
aueurismal  tumor.  He  may  be  led  to  suspect  this  affection,  but 
he  is  never  justified  in  deciding  with  any  positiveness  that  it  exists. 
The  circumstances  favoring  such  a  suspicion,  are  those  which  show 
that  some  anomalous  form  of  disease  is  present.  For  example,  as 
remarked  by  Hope,  an  endocardial  murmur  may  be  found  which 
is  not  referable  to  the  arterial  or  auricular  orifices  by  the  rules  of 
localization  to  be  hereafter  considered.  Valvular  lesions,  as  the 
source  of  the  murmur,  being  thus  excluded,  and  the  murmur  being 
evidently  due  to  some  organic  affection,  the  hypothesis  of  cardiac 
aneurism  is  admissible ;  but  intra- ventricular  murmur  is  sometimes 
produced,  not  referable  to  the  orifices,  and,  on  the  other  hand, 
aneurismal  dilatations  do  not  always  give  rise  to  murmur.  So  a 
pericardial  or  friction  murmur  may  proceed  from  various  conditions, 
irrespective  of  present  pericarditis.  In  short,  the  diagnosis  is  neces- 
sarily unattainable.  The  affection  is  one  of  the  rare  forms  of  disease 
which  give  rise  to  more  doubt  and  difficulty,  the  better  acquainted 
the  practitioner  is  with  the  diagnostic  signs  and  symptoms  of  cardiac 
lesions.  He  may  be  aware  that  he  has  to  deal  with  some  anomalous 
affection,  but  he  is  unable  to  determine  its  character.  Here,  as  in 
other  similar  instances,  the  inability  to  arrive  at  the  diagnosis  is 
not,  in  a  practical  point  of  view,  to  be  deplored ;  for,  were  the 
existence  of  cardiac  aneurism  determinable,  the  treatment  would 


RUPTURE    OF    HEART.  115 

be  that  whicli  is  indicated  by  the  symptoms  without  this  knowledge. 
The  lesion  is  irremediable,  and  the  measures  best  suited  to  retard 
the  dilatation  and  prolong  life,  are  those  which  are  applicable  to 
cases  of  valvular  lesions  and  enlargement,  with  which  the  affection 
is  often  associated. 


RUPTURE   OF    THE    HEART. 


Spontaneous  rupture  of  the  heart  is  a  lesion  of  very  rare  occur- 
rence. It  may  fairly  be  doubted  if  it  has  ever  occurred  as  a  result 
purely  of  the  violent  muscular  activity  of  the  organ.  In  a  physical 
point  of  view,  a  broken  heart  is  a  poetical  license,  exclusive  of  the 
cases  in  which  the  event  is  dependent  on  some  prior  morbid  condi- 
tion of  the  cardiac  parietes.  It  is  an  accident  incidental  to  different 
local  affections.  In  the  great  majority  of  cases,  it  takes  place  in 
consequence  of  softening  from  fatty  degeneration.  It  may  follow 
extravasation  into  the  muscular  substance,  constituting  the  condi- 
tion called  by  the  French  writers  apoplexy  of  the  heart,  which  has 
been  investigated  fully  by  Cruveilhier;  great  attenuation  of  the 
walls  in  some  cases  of  dilatation ;  circumscribed  abscess ;  ulcerative 
perforation  of  the  endocardium ;  and  softening  from  inflammation. 
The  seat  of  rupture,  in  the  vast  majority  of  instances,  is  the  left 
ventricle,  either  on  the  anterior  or  posterior  surface.  Statistics 
differ  as  to  the  relative  liability  of  the  two  surfaces.  It  has  been 
observed  in  the  auricles  as  well  as  in  either  ventricle.  Usually  a 
single  opening  takes  place,  varying  in  size  from  a  very  minute 
aperture  to  a  rent  of  considerable  size ;  but  instances  have  been 
reported  of  rupture  simultaneously  at  several  different  points.  It 
occurs  oftener  in  the  male  than  in  the  female,  and  almost  alwaj-s  at 
an  advanced  period  of  life.  The  coexistence  of  hypertrophy  or  of 
aortic  obstruction  favors  its  occurrence.  It  may  be  attributable  to 
some  unusual  muscular  exertion  acting  as  an  exciting  cause,  but  in 
a  large  proportion  of  the  reported  cases,  the  patients  were  in  a  state 
of  repose  when  it  took  place.^  The  only  instance  of  ruptifre  which 
has  fallen  under  my  observation  occurred  in  a  patient  admitted  into 

'  Vide  paper  by  Dr.  Hallowell,  of  PhiladelpMa,  giving  an  analysis  of  thirty-four 
cases,  in  the  American  Journal  of  Medical  Sciences,  1835.  For  copious  references 
to  the  literature  of  this  subject  see  Bellingham,  op.  cit.,  part  H.,  1857. 


116      LESIONS    AFFECTING   THE    WALLS    OF    THE    HEART. 

the  Charity  Hospital  at  New  Orleans  with  delirium  tremens.  I  did 
not  see  the  patient  during  life.  He  died  suddenly  and  unexpect- 
edly, no  affection  of  the  heart  having  been  suspected.  On  exami- 
nation after  death,  a  rent  was  found  at  the  upper  and  anterior  part 
of  the  right  ventricle  near  the  pulmonary  artery.  The  inner  layer 
of  muscular  fibres  was  torn  over  a  space  wider  than  the  external 
opening,  showing  the  gradual  progress  of  the  disruption  from 
within.  The  heart  was  enlarged,  weighing  a  fraction  over  fourteen 
ounces.  The  ventricular  walls  were  not  increased  in  thickness. 
The  right  ventricle  was  covered  with  fat,  and  the  walls  presented 
both  the  gross  and  microscopical  characters  of  advanced  fatty 
degeneration.  At  certain  points,  fatty  matter  appeared  to  have 
replaced  the  greater  part  of  the  ventricular  walls,  the  muscular 
tissue  being  reduced  to  a  thin  layer,  not  more  than  a  line  in  thick- 
ness. The  patient  was  about  sixty-five  years  of  age.  The  previous 
history  of  the  case  was  not  ascertained. 

Rupture  of  the  heart  is  almost  inevitably  fatal,  and  death  gene- 
rally follows  at  once.  In  some  instances,  however,  life  has  con- 
tinued for  several  hours.  The  aperture  in  these  instances  was 
quite  small,  or  the  escape  of  blood  was  retarded  by  the  formation 
of  a  coagulum  at  the  point  of  rupture.  A  repair  of  the  solution  of 
continuity  is  perhaps  not  impossible,  although  infinitely  improba- 
ble. Dr.  Walshe  states  that  one  case  has  been  recorded  of  death 
from  rupture  in  which  a  former  rupture  was  discovered,  firmly 
filled  by  a  fibrinous  coagulum  adherent  to  the  wall  of  the  heart. 
The  mechanism  by  which  the  fatal  result  is  produced  has  given 
rise  to  considerable  discussion.  Blood  is  poured  into  the  pericar- 
dial sac  with  more  or  less  rapidity  according  to  the  extent  of  the 
rupture.  But  this  sac  will  not  contain  sufficient  liquid  for  death  to 
be  referred  to  the  hemorrhage  alone.  Paralysis  of  the  heart  from 
the  mechanical  compression  of  the  accumulation  of  blood  within 
the  pericardial  sac  is  doubtless  an  important  agency. 

Time  and  opportunity  are  seldom  offered  for  an  investigation 
with  reference  to  diagnosis.  If  life  be  prolonged  for  some  hours, 
the  symptoms  are  those  which  denote  syncope  with  prcecordial 
distress,  and  coma  may  ensue  before  dissolution.  Happily  here,  as 
in  other  instances  in  which  a  positive  diagnosis  is  unattainable,  it 
would  not,  if  attainable,  affect  the  treatment.  The  indications 
derived  from  the  symptoms  alone  are  those  which  would  be  fur- 
nished by  the  knowledge  of  the  accident  which  has  occurred. 
Death  occurring  suddenly,  or  a  few  hours  after  the  sudden  develop- 


RUPTUEE    OF    HEART.  117 

ment  of  alarming  syncope,  in  a  person  advanced  in  years,  who  had 
previously  presented  evidence  of  cardiac  disease,  and  especially  of 
fatty  degeneration,  warrants  a  strong  suspicion  of  rupture. 

Rupture  of  the  valves  of  the  heart,  or  of  the  tendinous  cords  and 
papillary  muscles,  falls  more  appropriately  under  the  head  of  val- 
vular lesions  than  in  the  present  connection. 

In  addition  to  the  lesions  affecting  the  walls  of  the  heart,  which 
have  been  considered  in  this  chapter,  there  are  some  others, 
extremely  rare  and  unattended  by  any  distinctive  symptoms  or 
signs,  and,  therefore,  of  little  interest  or  importance  in  a  practical 
point  of  view.  Carcinomatous  and  tuberculous  deposits  have  been 
known  to  extend  from  beneath  the  endocardial  and  pericardial 
membranes  more  or  less  into  the  muscular  substance  of  the  organ. 
Few  organs  of  the  body,  however,  are  more  exempt  from  these 
heteromorphous  formations  than  the  heart.  So  slight  is  the  pro- 
bability of  their  existence  in  a  given  individual  case,  that  they  are 
scarcely  to  be  taken  into  account  in  the  investigation  of  cardiac 
affections  which  are  evidently  anomalous.  The  presence  of  these 
deposits  in  other  parts  of  the  body  may  constitute  a  slight  ground 
for  suspicion  that  they  have  invaded  the  heart,  if  the  signs  and 
symptoms  show  that  the  organ  is  affected  with  some  indeterminable 
form  of  disease.  In  this  category  are  to  be  included  extravasation 
of  blood,  or  cardiac  apoplexy,  to  which  allusion  has  been  already 
made,  and  cysts  containing  entozoa. 


CHAPTER   III. 

LESIONS  AFFECTING  THE  YALVES  AND   ORIFICES 
OFTHE   HEART. 

Aortic  lesions — Mitral  lesions — Primary  effects  of  valvular  lesions  on  the  circulation — 
Points  to  be  observed  in  post-mortem  examinations — Pathological  processes  involved  in 
the  production  of  valvular  lesions — Symptoms  and  secondary  pathological  effects  of 
lesions  affecting  the  valves  and  orifices  of  the  heart — Symptoms  and  pathological  effects 
referable  to  the  heart — Enlargement  of  the  several  portions  of  the  heart  in  relation  to 
mitral,  aortic,  tricuspid,  and  pulmonic  lesions,  respectively — Pain,  palpitation,  the  pulse, 
venous  turgescence,  and  pulsation — Symptoms  and  pathological  effects  referable  to  the 
circulation — Cardiac  dropsy — Arterial  obstruction  by  fibrinous  deposits  detached  from 
the  valves  or  orifices  of  the  heart  (embolia) — Symptoms  and  pathological  effects  refera- 
ble to  the  respiratory  system  :  Dyspnoea,  cardiac  asthma,  cough,  muco-serous  expectora- 
tion and  haemoptysis,  pulmonary  apoplexy  and  oedema,  bronchitis,  pneumonitis,  pleurisy, 
and  emphysema — Symptoms  and  pathological  effects  referable  to  the  nervous  system  : 
Apoplexy,  paralysis,  arterial  obstruction,  defective  supply  of  blood  to  brain,  pseudo- 
apoplexy,  cephalalgia,  vertigo,  tinnitus  aurium,  etc.,  sleep,  mental  condition — Symp- 
toms and  pathological  effects  referable  to  the  digestive  system  and  nutrition  :  Hepatic 
congestion,  nutmeg  liver,  portal  congestion,  enlargement  of  liver,  cirrhosis,  indigestion, 
haematemesis,  enterorrhoea,  melsena,  haemorrhoids,  enlargement  of  spleen,  nutrition — 
Symptoms  and  pathological  effects  referable  to  the  genito-urinary  system  :  Congestion  of 
kidneys,  diminished  secretion  of  urine,  albuminuria,  structural  degenerations  of  kidney, 
or  Bright's  disease — Generative  functions — Symptoms  and  pathological  effects  referable 
to  the  countenance  and  external  appearance  of  the  body  :  Lividity,  expression,  anaemia, 
capillary  congestion,  erythema,  bloodless  fingers. 

Lesions  of  the  valves  or  orifices  of  the  heart,  or  valvular  lesions^ 
as  thej  are  concisely  called,  are  present  in  a  very  large  proportion 
of  the  cases  of  organic  disease  of  this  organ  which  come  under  the 
cognizance  of  the  physician.  In  addition  to  the  intrinsic  interest 
■which  they  possess  as  subjects  for  clinical  study,  they  are  important 
as  standing  in  a  causative  relation  to  other  cardiac  lesions,  more 
especially  enlargement  of  the  heart,  and  also  as  giving  rise  to 
pathological  effects  manifested  in  other  parts  of  the  body.  They 
are  important  as  sustaining  a  relation  of  dependence  to  other  dis- 
eases, particularly  acute  rheumatism,  a  relation  which  has  been 
established  by  modern  researches.  In  connection  with  physical 
signs,  and  as  exemplifying  the  wonderful  precision  of  diagnosis 
which  has  resulted  from  the  application  of  auscultation  within  the 


I 


VALVULAR    LESIOXS.  119 

past  few  years,  the  clinical  study  of  these  lesions  is  highly  interest- 
ing. Inquiries  with  respect  to  their  origin  and  mode  of  production 
involve  pathological  points  of  much  interest  and  importance.  To 
the  latter,  brief  reference  will  alone  be  made,  a  full  discussion  of 
them  being  inconsistent  with  the  practical  objects  of  this  work. 
The  various  morbid  appearances  incidental  to  the  lesions  will  be 
summarily  considered,  a  lengthened  description  belonging  more 
appropriately  to  works  on  pathological  anatomy.  In  treating  of 
valvular  lesions,  the  main  objects  will  be  to  show  their  immediate 
and  remote  effects,  the  symptomatic  phenomena  to  which  they  give 
rise,  their  physical  signs  and  diagnosis,  and,  finally,  the  indications 
for  treatment.  The  physical  signs  of  these  lesions  consist  of  abnor- 
mal modifications  of  the  natural  heart-sounds,  and  also  of  super- 
added adventitious  sounds  distinguished  as  murmurs.  The  import- 
ance of  the  latter,  and  the  various  considerations  connected  with 
their  diagnostic  application,  require  that  they  should  be  treated  of 
at  some  length. 

Lesions  of  the  valves  and  orifices  of  the  heart,  exclusive  of  con- 
genital malformations,  are  seated  as  a  rule  in  the  left  half  of  the 
organ ;  that  is  to  say,  in  the  great  majority  of  cases  they  are  either 
mitral  or  aortic.  The  tricuspid  and  pulmonic  valves  and  orifices 
rarely  become  affected  after  birth.  Still  more  unfrequently  do  the 
latter  present  extensive  structural  alterations  such  as  are  often 
found  in  the  corresponding  situations  in  the  left  half.  When  they 
occur,  they  are  generally,  but  not  invariably,  associated  with  mitral 
and  aortic  lesions.  It  is  a  curious  fact  that  the  lesions  of  foetal 
life,  giving  rise  to  the  congenital  malformations  which  will  be  no- 
ticed in  a  subsequent  chapter,  affect  by  preference  the  right  half 
of  the  heart,  reversing  the  rule  which  obtains  after  birth.  The 
changes  which  the  valves  and  orifices  present  in  different  cases, 
vary  greatly  in  degree  and  kind.  The  morbid  appearances  are 
exceedingly  diversified.  As  before  remarked,  a  full  description 
of  these  belongs  more  appropriately  to  the  works  on  pathological 
anatomy,  and  to  these  the  reader  is  referred.^  I  shall  content 
myself  with  a  simple  enumeration  of  the  more  prorftiifent  forms  or 
varieties,  considering  the  aortic  and  the  mitral  lesions  under  distinct 
heads.  Pulmonic  and  tricuspid  lesions  will  be  noticed  in  connec- 
tion with  the  pathological  effects  of  valvular  lesions,  referable  to 
the  heart,  and  also  in  treating  of  congenital  malformations. 

'  Rokitansky's  great  work,  or  Jones  and  Sievekiug,  may  be  consulted  for  this 
purpose. 


120      LESIONS    AFFECTING   THE    VALVES    OF    THE    HEART. 

Aortic  Lesions. — Lesions  may  be  coufiaed  to  one  or  two  of  the 
semilunar  segments;  but  in  general  all  are  more  or  less  affected, 
although  rarely  in  an  equal  degree.  The  segments  may  be  simply 
thickened  and  somewhat  contracted.  If  the  contraction  be  not 
enough  to  render  them  insufficient,  that  is,  permitting  regurgita- 
tion, the  thickening  only  renders  their  action  less  free  than  in  health. 
One  or  both  the  surfaces  may  present  vegetations  or  excrescences, 
varying  in  size  from  a  pin's  head  to  a  pea  or  bean.  These  are 
frequently  situated  on  or  near  the  free  extremity  of  the  segments. 
I  have  seen  in  one  case  masses  resembling  fibrin  attached  to  the 
lower  surface,  as  large  collectively  as  a  walnut,  hanging  down- 
ward an  inch  within  the  ventricle.  These  vegetations  are  sometimes 
easily  detached,  so  easily  as  to  render  it  altogether  probable  that 
they  are  sometimes  washed  away  by  the  current  of  blood  during 
life.  In  other  instances  they  are  firmly  attached.  They  must,  in 
proportion  to  their  number  and  size,  embarrass  the  movements  of 
the  valve.  Morbid  growths  of  cartilaginous  hardness,  and  calca- 
reous deposits  are  often  found  situated  at  the  attached  margins 
of  the  semilunar  segments,  extending  partially  or  entirely  over 
them.  These  render  the  segments  more  or  less  rigid  and  perma- 
nently expanded.  One  or  more  of  them  may  be  thus  affected. 
In  proportion  to  the  amount  of  morbid  material,  and  the  space 
which  the  expanded  segment  or  segments  occupy,  will  the  size  of 
the  arterial  orifice  be  diminished,  and  the  current  of  blood  broken 
and  interrupted.  Occasionally  the  segments  become  united  at  their 
sides,  and,  remaining  expanded,  the  orifice  is  diminished  to  a  small 
aperture.  I  have  seen  it  as  small  as  a  crow's  quill ;  it  has  been 
observed  even  considerably  smaller  than  this,  so  as  hardly  to  admit 
the  passage  of  a  fine  probe.  One  or  more  of  the  segments  may  be 
expanded  and  crumpled,  being  bent  either  upward  or  downward. 
They  are  sometimes  greatly  shrivelled  or  corrugated,  ]eaving  a  per- 
manently open  aperture  of  greater  or  less  size.  The  partition 
between  two  of  the  segments  is  occasionally  wanting,  fusion  into  a 
single  segment  having  taken  place.  It  is  sometimes  difficult  to  say 
whether  this  is  due  to  disease  after  birth,  or  a  congenital  malforma- 
tion. Attenuation  of  the  segments  is  another  variety  of  lesion,  a 
species  of  atrophy,  and  in  this  condition  they  are  liable  to  become 
perforated  or  cribriform. 

Finally,  rupture  may  take  place  in  different  directions.  A  seg- 
ment may  be  torn  vertically  from  the  free  margin  toward  the  base; 
it  may  be  partially  torn  away  from  its  attachment,  or  there  may  be 


MITRAL    LESIONS.  121 

one  or  more  fissures  at  the  base,  the  lateral  ends  renaaining  attached. 
These  different  varieties  of  lesion  are  bj  no  means  observed  sepa- 
rately in  different  cases,  but  they  are  usually  to  a  greater  or  less 
extent  combined  in  the  same  case.  • 

Mitral  Lesions. — These  are  essentially  the  same  as  the  aortic 
lesions,  the  points  of  difference  relating  chiefly  to  the  different  form 
and  arrangement  of  the  mitral  valve.  They  consist  of  thickening 
and  contraction  of  the  valvular  curtains ;  rigidity  from  calcareous 
deposit ;  attenuation  and  perforation ;  adhesion  of  the  sides  of  the 
two  curtains,  giving  rise  to  a  funnel  shaped  canal  from  the  auricle 
to  the  ventricle,  opening  into  the  latter  by  a  slit  or  small  aperture ; 
adhesion  of  the  curtains  to  the  walls  of  the  heart;  shortening  and, 
in  some  instances,  cretaceous  hardness  and  brittleness  of  the  ten- 
dinous cords ;  accumulation  of  masses  of  calcareous  matter  at  the 
base  of  the  curtains,  diminishing  the  size  of  the  auriculo-ventricular 
orifice,  and  presenting  an  irregular  surface  to  the  current  of  blood ; 
rupture  of  the  curtains  in  various  directions  and  of  the  tendinous 
cords ;  warty  vegetations  or  excrescences  and  deposit  of  fibrin  in 
masses  of  variable  form  and  size,  adhering  loosely  or  firmly,  etc. 
This  valve  is  subject  to  circumscribed  dilatations  called  aneurisms, 
which  form  pouches  varying  from  the  size  of  a  pea  to  that  of  a 
walnut,  protruding  into  the  cavity  of  the  auricle,  and  containing 
coagula  or  laminated  fibrin.  These  aneurismal  dilatations  present, 
in  some  instances,  all  the  membranous  structures  of  the  valve 
unbroken,  and,  in  other  instances,  perforation  of  one  of  the  endo- 
cardial laminae,  the  distinction  between  false  and  true  aneurisms 
being  thus  maintained  here  as  in  aneurismal  dilatations  of  the 
cardiac  walls.     This  variety  of  lesion  is  of  rare  occurrence. 


The  foregoing  summary  of  the  various  lesions  affecting  the 
valves  and  orifices  of  the  heart  is  intended  merely  to  refresh  the 
memory  of  the  reader.  In  order  to  form  a  proper  idea  of  the  great 
diversity  of  morbid  appearances,  it  is  important  to  consult  works 
on  morbid  anatomy  in  which  they  are  fully  described  and  illus- 
trated, and,  as  far  as  practicable,  also  to  examine  morbid  specimens. 
The  immediate  pathological  importance  of  the  lesions  depends  on 
the  primary  effects  which  they  produce  on  the  blood-currents. 
Arranged  with  reference  to  these  effects,  they  may  be  distributed 
into  three  classes,  to  wit :  First^  as  involving  obstruction  to  the 


122      LESIONS    AFFECTING   THE    VALVES    OF    THE    HEART. 

onward  or  direct  blood-currents;  second^  as  inducing  insufficiency  of 
the  valves  and  allowing  regurgitation  or  retrograde  currents ;  and, 
thirds  as  interfering  more  or  less  with  the  freedom  of  the  action  of 
the  valves  and  roughening  surfaces  which  are  normally  smooth  and 
polished,  but  without  giving  rise  to  either  obstruction  or  insuffi- 
ciency. Of  these  three  divisions,  according  to  the  primary  effects 
of  the  lesions,  the  two  first  alone  possess  much  immediate  patho- 
logical importance.  The  last  class  of  lesions  affect  the  blood- 
currents  but  little  or  not  at  all.  Their  pathological  importance  is 
remote,  that  is,  it  relates  to  a  prospective  period  when,  by  ending 
in  more  serious  changes,  they  may  induce  either  obstruction  or 
insufficiency.  In  the  clinical  study  of  valvular  lesions,  however,  it 
is  highly  important,  as  will  hereafter  appear,  to  bear  in  mind  the 
fact  that  abnormal  conditions  may  exist  which  are  not  of  immediate 
pathological  importance,  inasmuch  as  they  do  not  involve  either 
contraction  of  the  orifices  or  regurgitation,  but  which  give  rise  to 
physical  signs.  To  this  important  fact  reference  will  again  be 
made. 

The  primary  effects  of  valvular  lesions  on  the  circulation,  which 
are  of  a  nature  to  possess  immediate  pathological  importance,  are, 
then,  produced  by  means  of  obstruction  and  insufficiency.  Other 
things  being  equal,  the  degree  of  importance  belonging  to  these 
effects  is  proportionate  to  the  amount  of  obstruction  and  insuffi- 
ciency. Obstruction  may  exist  without  insufficiency,  and  vice  versa, 
but  it  often  happens  that  the  lesions  are  such  as  to  occasion  both  at 
the  same  time.  These  remarks  apply  indifferently  to  aortic  and  to 
mitral  lesions.  Now,  aortic  lesions  may  exist  without  mitral  lesions, 
and  vice  versa,  but  frequently  lesions  are  present,  in  the  same  case, 
in  both  situations.  Cases  are  greatly  diversified  by  the  different 
combinations  of  aortic  and  mitral  lesions  and  their  primary  effects. 
Thus,  there  may  be  lesions  of  either  the  aortic  or  mitral  orifice 
separately,  which  involve  insufficiency  without  obstruction ;  the 
lesions  in  either  situation  may  occasion  obstruction  without  insuffi- 
ciency ;  obstructive  aortic  lesions  may  be  associated  with  regurgitant 
mitral  lesions,  or  vice  versa;  there  may  be  obstruction,  or,  on  the 
other  hand,  regurgitation,  both  at  the  aortic  and  mitral  orifice,  and, 
finally,  aortic  and  mitral  lesions  may  coexist,  each  involving  both 
obstruction  and  insufficiency.  These  various  combinations  would 
seem  to  render  the  clinical  study  of  the  valvular  lesions  extremely 
complicated,  but  the  application  to  this  study  of  physical  explora- 
tion has  rendered  it  practicable,  in  most  cases,  to  determine  whether 


EXAMINATION   AFTER    DEATH.  123 

aortic  or  mitral  lesions  exist  separately  or  combined,  whether  ob- 
struction or  regurgitation,  or  both,  are  produced  by  existing  lesions, 
and  to  estimate  the  amount  of  damage  which  the  heart  has  sustained. 
The  reader  will  be  better  able  to  judge  of  the  correctness  of  this 
statement  after  the  physical  signs  and  diagnosis  have  been  con- 
sidered. 

As  regards  relative  frequency  in  the  occurrence  of  mitral  and 
aortic  lesions,  in  my  own  experience,  the  former  slightly  preponde- 
rate. Of  104  recorded  cases,  in  40  the  lesions  were  mitral,  and  in 
37  aortic.  In  14  of  these  cases  mitral  and  aortic  lesions  coexisted, 
and  in  4  cases  only  were  the  tricuspid  or  pulmonic  valves  the  seat  of 
lesions.  Of  367  cases  analyzed  by  Dr.  T.  K.  Chambers,  the  mitral  and 
aortic  valves  were  affected  with  thickening,  contraction,  or  morbid 
deposit  in  121 ;  the  aortic  valves  were  affected  alone  in  107 ;  the 
mitral  in  96;  the  mitral  and  tricuspid  valves  in  10;  the  mitral, 
aortic,  and  tricuspid  in  10 ;  the  four  sets  of  valves  in  9  ;  the  tricus- 
pid alone  in  1 ;  the  tricuspid  and  aortic  in  2 ;  the  aortic,  mitral,  and 
pulmonary  in  2  ;  the  tricuspid  and  aortic  in  2  ;  and  the  aortic  and 
pulmonary  valves  in  4.^ 

In  determining  the  pathological  importance  of  lesions  at  post- 
mortem examinations,  the  points  for  observation  are  embraced  in 
the  following  questions :  Is  there  contraction  of  one  or  more  of  the 
orifices,  and,  if  so,  to  what  extent?  Are  the  arterial  or  auricular 
valves  sufficient  to  protect  the  orifices,  and,  if  not,  how  great  is  the 
insufficiency  ?  These  points  are  to  be  settled  by  laying  open  the 
cavities  and  carefully  examining  the  orifices  and  valves.  With  a 
proper  knowledge  of  the  normal  appearances,  the  existence  or 
otherwise  of  contraction  or  insufficiency  may  be  readily  ascertained 
by  the  eye,  and  the  amount  of  obstruction  or  regurgitation  esti- 
mated accurately  enough  for  practical  purposes.  The  sufficiency 
or  insufficiency  of  the  aortic  valve  may  be  ascertained,  before  lay- 
ing open  the  cavities  and  vessels,  by  resorting  to  the  water  test. 
This  test  consists  in  suspending  the  heart  by  hooks  introduced  into 
the  aorta  above  the  valves,  having  first  tied  the  coronary  arteries 
and  opened  the  left  ventricle  by  slicing  oft"  the  apex  of  the  organ, 
and  then  pouring  a  stream  of  water  into  the  aorta.  If  the  valve  be 
sufficient,  little  or  no  water  passes  into  the  ventricle ;  but  if  there 

'  Decennium  Pathologicum.  Brit,  and  For.  Med.-Chir.  Rev.,  vol.  sii.,  1S53.  In 
tliese  cases  were  probably  included  cases  of  congenital  malformation.  The  valves 
were  affected  in  3(J7  of  21  Gl  bodies  examined. 


124-      LESIONS   AFFECTING    THE    VALVES    OF   THE    HEART. 

be  insufficiency,  the  water  escapes  more  or  less  freely  from  the 
opening  at  the  apex.  This  test  is  far  less  reliable  in  its  application 
to  the  mitral  valve.  It  is  applied  to  this  valve  by  suspending  the 
heart  with  the  apex  upwards,  the  left  ventricle  having  been  opened, 
and  the  aorta  and  coronary  arteries  tied.  If  water  poured  into  the 
opening  at  the  apex  do  not  pass  into  the  left  auricle,  the  mitral 
valve  is  sufficient.  This  test  demonstrates  sufficiency  in  a  certain 
number  of  cases.  But  if  the  water  pass  into  the  auricle,  it  does  not 
follow  that  the  mitral  valve  was  insufficient  durinsr  life,  the  condi- 
tions  being  so  widely  different  in  this  experiment.  If  the  orifices 
are  contracted  so  as  to  oppose  an  obstacle  to  the  blood-current,  it  is 
obvious  to  the  eye,  provided  the  observer  have  been  accustomed  to 
examine  hearts  in  which  the  size  of  the  orifices  is  normal.  In 
recording  post-mortem  observations,  it  has  been  customary  to  note 
how  many  fingers  may  be  passed  readily  through  the  orifice.  This 
is  a  rough  method  of  measurement,  but  in  most  instances  it  is 
sufficiently  precise.  Greater  accuracy,  of  course,  is  obtained  by 
actual  measurement  either  of  the  diameter  or  circumference.  As 
standards  of  comparison,  the  average  size  in  healthy  hearts  is  to  be 
determined.  The  numerous  measurements  by  Bizot  give  the  fol- 
lowing mean  results:  The  average  circumference  of  the  mitral 
orifice  in  the  adult  male  is  about  four  inches.  The  long  diameter, 
according  to  Dr.  Bellinghara,  is  about  one  inch.  In  the  female, 
the  size  is  somewhat  less.  The  averao;e  circumference  of  the  aortic 
orifice  in  the  adult  male  is  three  inches;  the  diameter,  according  to 
Dr.  Bellingham,  is  about  an  inch.  In  the  female,  the  size  is  some- 
what less.  The  tricuspid  orifice  is  somewhat  larger  than  the  mitral, 
in  health ;  and  this  is  true  of  the  pulmonic  orifice  prior  to  the  age 
of  fifty.  The  observations  of  Bizot  show  that  the  orifices,  as  well 
as  the  heart  itself,  increase  in  size  gradually  from  birth  to  old  age. 
What  pathological  processes  are  involved  in  the  production  of 
valvular  lesions?  This  question  claims  a  few  words  before  passing 
to  consider  the  symptoms  and  pathological  effects  of  these  lesions. 
It  opens  up  a  broad  field,  embracing  mooted  topics,  the  discussion 
of  which  does  not  fall  within  the  scope  of  this  work.  I  shall 
present  very  briefly  the  general  views  which  appear  to  be  most 
consistent  with  our  present  knowledge,  and  which  are  of  import- 
ance in  their  practical  bearings.  Thickening  of  the  valves,  the 
accumulation  of  fibrinous  matter  in  the  form  of  vegetations  or 
excrescences,  and  calcareous  concretions,  are  due  to  abnormal 
deposit,  which  may  either  take  place  as  an  exudation  from  the 


PRODUCTION    OF    VALVULAR    LESIONS.  125 

bloodvessels  or  be  derived  from  the  blood  contained  witliin  the 
heart-cavities.  It  is  certain  that  both  of  these  sources  of  deposit 
are  concerned  in  the  changes  referred  to.  When  fibrinous,  cal- 
careous, or  other  matter  is  situated  beneath  the  endocardial  mem- 
brane, it  must  be  an  exudative  deposit.  An  organized  growth  is 
to  be  considered  as  exudative.  On  the  other  hand,  it  is  sufficiently 
well  ascertained  that  more  or  less  of  the  deposit,  in  certain  instances, 
proceeds  from  fibrin  attracted  from  the  blood  exterior  to  the  vessels, 
i.  e.,  within  the  chambers  of  the  heart.  Roughness  of  the  endo- 
cardial membrane  conduces  to  deposit  from  this  source.  This  is 
illustrated  bj  Mr.  Simon's  experiment  of  passing  a  thread  through 
an  artery ;'  fibrin  coagulates  and  adheres  to  the  thread,  presenting 
an  appearance  not  unlike  the  so-called  vegetations  sometimes 
observed  on  the  valves.  It  is  by  no  means  probable  that  these 
fibrinous  concretions  are  organizable.'^  There  is  reason  to  suppose 
that  their  production  is  favored  by  certain  conditions  of  the  blood, 
such  as  a  superabundance  of  the  fibrinous  element,  which  occurs  in 
various  affections,  and  especially  in  acute  rheumatism.  The  deposit 
from  either  source  undergoes  metamorphoses,  produced  by  the 
elimination  of  certain  constituents  and  the  addition  of  others. 
Thus,  a  deposit  primarily  fibrinous,  may  become,  in  the  course  of 
time,  calcareous.  The  contraction  or  shortening  of  valves,  their 
rigidity  and  permanent  expansion,  crumpling,  rupture,  etc.,  are 
ulterior  results  of  deposit  and  the  metamorphoses  which  it  under- 
goes. Attenuation  and  cribriform  perforations  are  due  to  defective 
nutrition  or  atrophy,  which  may  render  the  valves  unable  to  sustain 
the  pressure  of  the  blood,  and  give  rise  to  laceration.  By  a  per- 
version of  nutrition,  also,  according  to  Rokitansky,  a  gelatinous 
substance  is  sometimes  substituted  for  the  fibrous  tissue  of  the 
valves,  rendering  them  weak  and  liable  to  rupture.  To  what 
extent  is  inflammation  involved  in  these  processes?  Post-mortem 
examinations,  when  death  has  occurred  during  or  shortly  after  an 
attack  of  acute  endocarditis,  have  shown  that  the  inflammation 
affects  more  especially  the  valves,  and  leads  to  deposit  both  by 
exudation  and  coagulation.  Moreover,  clinical  observation  shows 
that,  in  the  great  majority  of  the  cases  of  valvular  lesions,  the 
persons  affected  have,  at  some  former  period  of  their  lives,  expe- 

'  Lectures  on  General  Pathology. 

'^   Vide  Ch.  Robin  in  Dictionnaire  de  Medecine,  par  Nysten,  1854 ;  also  Chimie 
Anatomique,  par  Robin  et  Verdeil. 


126      LESIONS    AFFECTING   THE    VALVES    OF    THE    HEAKT. 

rienced  one  or  more  attacks  of  acute  rheumatism,  a  disease  which 
clinical  observation,  within  late  years,  also  has  shown  to  be  com- 
plicated witli  endocarditis  in  a  large  proportion  of  instances.'  From 
these  facts  it  may  be  logically  inferred  that  valvular  lesions  ori- 
ginate most  frequently  in  endocardial  inflammation.  The  imme- 
diate local  effects  of  endocarditis,  as  will  be  seen  when  we  come  to 
treat  of  that  affection,  are  generally  unimportant.  During  the 
progress  of  the  endocarditis,  and,  perhaps,  for  many  years  after- 
wards, there  may  be  no  obvious  symptoms  denoting  cardiac  lesions. 
The  structural  changes  which  these  effects  gradually  induce,  at 
length  give  rise  to  obstruction  or  regurgitation,  or  both,  and,  finally, 
symptoms  are  developed  which  point  to  the  heart  as  the  seat  of 
disease.  When,  thus,  inflammation  constitutes  the  first  step  in  the 
production  of  lesions  of  structure,  it  is  a  by-gone  and  remote  event 
at  the  time  these  lesions  have  become  of  immediate  pathological 
importance;  it  has  long  before  ceased  to  be  an  active  element  of 
the  cardiac  affection,  its  products,  with  their  metamorphoses,  and 
the  changes  induced  by  them,  having,  by  degrees,  led  to  the  exist- 
ing morbid  condition  of  the  organ.  But  it  is  not  probable  that  the 
lesions  originate  always  in  inflammation.  An  exudation  similar 
to  that  which  constitutes  the  atheroma  of  arteries  is  apparently 
the  first  event  in  some  cases.  This  cannot  be  considered  as  involv- 
ing inflammation,  unless  the  term  be  so  defined  as  to  embrace 
every  process  attended  by  a  solidifying  deposit.  There  is  no 
ground  to  suppose  that  attenuation  or  atrophy,  and  the  gelatinous 
degeneration  described  by  Eokitansky,  are  dependent  on  an  inflam- 
matory action. 

'  Of  sixty-one  cases  of  valvular  lesions,  in  the  histories  of  which,  the  existence  or 
nou-existence  of  rheumatism  at  a  former  period  of  life  is  noted,  this  affection  had 
occurred  in  forty-three.  Rheumatism  had  existed  in  a  larger  proportion  of  the 
cases  of  mitral  than  of  aortic  lesions.  Of  twenty-nine  cases  of  mitral  lesions,  rheu- 
matism had  occurred  in  twenty.  Oi  fourteen  cases  of  aortic  lesions,  rheumatism 
had  occurred  in  seven.  The  cases  of  aortic  and  mitral  lesions,  however,  presented 
the  largest  proportion  in  which  rheumatism  had  existed.  Of  eiyhteen  cases,  this 
affection  occurred  in  sixteen. 


OBSTKUCTIVE    AND    REGURGITANT   LESIONS.  127 


SYMPTOMS  AND  SECONDARY  PATHOLOGICAL  EFFECTS 
OF  LESIONS  AFFECTING  THE  VALVES  AND  ORIFICES 
OF  THE  HEART. 


The  primary  effects  of  valvular  lesions,  whicli  are  of  immediate 
pathological  importance,  have  been  already  considered.  They  are, 
obstruction  to  the  passage  of  blood  by  contraction  of  the  orifices, 
regurgitation  or  the  flow  of  blood  in  a  retrograde  direction  owing  to 
insufficiency  of  the  valves,  these  effects  being  produced  either 
separately  or  conjointly.  Hence,  the  lesions  affecting  the  valves  or 
orifices  may  be  distinguished  as  ohstructive  or  regurgitant  lesions ; 
and  as  all  the  valves  or  orifices  of  the  heart  may  be  affected  either 
separately  or  in  various  combinations,  valvular  lesions  may  be 
divided  after  their  seat  and  primary  effects  into  obstructive  and  re- 
gurgitant lesions,  situated  respectively,  at  the  mitral  and  aortic  ori- 
fices, and,  much  more  rarely,  at  the  pulmonic  and  tricuspid  orifices. 
The  secondary  or  remote  pathological  effects  of  these  lesions,  for  the 
most  part,  are  traceable  to  the  primary  effects.  The  disturbance  of 
the  circulation,  due  to  cardiac  obstruction  and  regurgitation,  singly 
or  combined,  gives  rise  to  a  great  number  and  variety  of  morbid 
conditions  and  manifestations  intrinsically  more  or  less  serious,  and 
important,  also,  as  symptoms  of  the  heart  affection.  It  will  be  most 
convenient  to  arrange  these  ulterior  effects  according  to  the  differ- 
ent anatomical  systems  in  which  they  occur.  Pathological  effects  of 
much  importance  are  produced  in  the  heart  itself;  other  effects  are 
appropriately  considered  as  pertaining  to  the  vascular  system,  not 
being  limited  in  their  consequences  to  any  particular  situation; 
others  relate  respectively  to  the  respiratory,  nervous,  digestive, 
genito-urinary  systems,  etc.  In  considering  the  effects  after  this 
arrangement,  their  relations  to  obstructive  and  regurgitant  lesions 
seated  at  the  different  orifices  will  be  incidentally  considered. 

Symptoms  and  Pathological  Effects  referable  to  the  Heart. 

Valvular  lesions  involving  obstruction  or  regurgitation,  sooner 
or  later,  in  the  great  majority  of  cases,  lead  to  enlargement  of 
the  heart.  They  lead  to  this  result  by  inducing  over-distension  of 
the  cavities  and  over-excitement  of  the  organ,  as  has  been  con- 


128      LESIOXS    AFFECTING    THE    VALVES    OF    THE    HEART. 

sidered  in  the  chapter  devoted  to  the  subject  of  enlargement.  The 
enlargement  may  be  due  either  to  predominant  hypertrophy  or 
dilatation.  The  latter  predominates  in  most  instances  in  which  the 
cardiac  disease  has  existed  for  a  long  period,  and  proved  directly 
fatal,  ^.  e.  when  death  is  not  attributable  to  an  intercurrent  affec- 
tion. The  hypertrophy  or  dilatation  is  generally  marked  in,  and 
may  be  limited  to  certain  portions  of  the  heart.  The  enlargement 
commences  at  one  of  the  ventricles  or  auricles,  according  to  the 
situations  of  the  valvular  lesions,  and  thence  extends  successively 
over  the  other  compartments,  observing  a  general  rule  of  extension, 
exceptions  to  the  rule,  however,  occurring  not  unfrequently. 

Obstructive  or  regurgitant  lesions  at  the  mitral  orifice  induce,  as 
a  rule,  first,  dilatation  of  the  left  auricle;  next,  dilatation  or  hyper- 
trophy of  the  right  ventricle ;  next,  dilatation  of  the  right  auricle, 
and  finally,  in  most  cases,  more  or  less  enlargement  either  by 
hypertrophy  or  dilatation  of  the  left  ventricle.  This  is  the  regular 
order  of  effects  upon  the  heart,  the  mechanism  of  which  has  been 
already  described.  Variations  from  this  rule  are  frequently 
observed.  Thus  the  right  auricle  is  sometimes  much  more  dilated 
than  the  left,  when  the  valvular  lesions  are  exclusively  mitral ;  and 
occasionally  under  these  circumstances,  the  left  ventricle  is  found 
to  be  more  enlarged  than  the  right.  In  these  exceptional  instances, 
either  the  walls  of  the  portions  which  are  enlarged  out  of  the 
natural  order,  are  particularly  prone  to  enlargement,  or  there  exists 
causes  superadded  to  the  valvular  lesions.  Thus,  emphysema,  co- 
existing with  mitral  lesions,  will  cause  the  enlargement  of  the  right 
ventricle  and  auricle  to  preponderate  much  more  than  if  the  mitral 
lesion  existed  alone.  In  some  cases,  superadded  causes  may  exist 
remote  from  the  heart,  which  are  not  readily  ascertained,  causing 
enlargement  of  the  left  ventricle  to  preponderate,  when,  as  a  result 
of  mitral  lesion  alone,  this  should  be  the  cavity  last  and  least  affected. 
As  an  exceptional  occurrence  the  left  ventricle  is  sometimes  dimi- 
nished in  size  when,  in  consequence  of  mitral  lesions,  the  other  por- 
tions are  enlarged.  This  fact,  first  pointed  out  by  Dr.  Law,  of 
Dublin,  is  explained  by  the  diminished  supply  of  blood  received 
by  that  ventricle  when  there  exists  much  obstruction  of  the  mitral 
orifice.  The  enlargement  of  one  ventricle  may  be  by  hypertrophy, 
and  that  of  the  other  by  dilatation.  Thus  the  right  ventricle  may 
be  hypertrophied  and  the  left  dilated,  or  vice  versa.  The  amount 
of  enlargement  of  the  heart,  as  a  whole,  varies  greatly  in  different 
cases,  and  what  is  remarkable,  is  not  proportionate  to  the  amount 


AORTIC    LESIONS,  129 

of  obstruction  or  regurgitation,  a  fact  which  shows  the  influence  of 
causes  •  subsidiary  to  the  valvuLar  lesions.  Very  great  enlarge- 
ment is  found  associated  with  lesions  involving  only  moderate 
obstruction  or  regurgitation,  and,  on  the  other  hand,  the  heart  is 
sometimes  found  to  be  but  little,  or  not  at  all  enlarged,  when  there 
exists  a  marked  degree  of  contraction  or  insufficiency.  The  mitral 
orifice  has  been  reduced  to  the  size  of  a  crow's  quill,  without  notable 
enlargement  of  any  of  the  cavities.^  This  fact  also  shows  the 
importance  of  causes  superadded  to  valvular  lesions.  As  a  rule, 
contraction  of  the  mitral  orifice,  in  other  words,  obstruction,  tends 
to  give  rise  to  enlargement,  more  than  insufficiency  or  regurgitation  ; 
but  the  tendency  is  of  course  greater  when,  as  is  frequently  the 
case,  contraction  and  insufficiency  are  conjoined.  The  latter  occurs 
in  the  instances  in  which  the  curtains  of  the  mitral  valve  become 
adherent  at  their  sides,  leaving  a  funnel-shaped  canal  opening  into 
the  ventricle  by  a  narrow  fissure  resembling  a  button-hole  or  the 
chink  of  the  glottis. 

Enlargement  proceeding  from  aortic  lesions  invariably  com- 
mences at  the  left  ventricle.  If  the  valvular  lesions  are  exclusively 
aortic,  this  ventricle  is  always  enlarged  disproportionately  to  the 
other  portions  of  the  heart,  and  the  enlargement  may  be  limited  to 
the  left  ventricle.  An  examination  of  the  heart  before  the  cavities 
are  opened  often  suffices  to  show  that  the  valvular  lesions  are  pro- 
bably aortic.  Either  hypertrophy  or  dilatation  may  predominate 
in  the  enlargement  proceeding  from  these  lesions.  As  a  rule,  if 
the  lesions  are  of  a  nature  to  allow  of  regurgitation  without  pro- 
ducing obstruction,  dilatation  predominates;  but  if  the  lesions 
produce  obstruction  without  regurgitation,  hypertrophy  is  marked. 
This  rule  is  not  without  exceptions,  but  it  holds  good  in  the  great 
majority  of  cases.  Thus,  of  21  cases  of  either  regurgitation  or 
obstruction,  the  notes  of  which  are  before  me,  3  only  were  excep- 
tional. Of  these  21  cases,  in  13  there  existed  regurgitation  without 
contraction,  and  in  2  cases  hypertrophy  was  predominant,  dilatation 
predominating  in  the  others ;  in  8  cases  there  was  obstruction  with- 
out regurgitation,  and  in  all  save  one  hypertrophy  was  predominant. 
Aortic  lesions,  however,  frequently  give  rise  both  to  obstruction 
and  regurgitation,  and  in  proportion  as  the  one  or  the  other  pre- 
ponderates, dilatation  or  hypertrophy  will  be  likely  to  be  marked. 

'  The  cabinet  of  the  Boston  Society  for  Medical  Improvement  contains  two  speci- 
mens, illustrative  of  this  statement,  vide  printed  catalogue,  pages  73  and  86. 

9 


180      LESIOXS    AFFECTING    THE    VALVES    OF    THE    HEART, 

Usually  the  enlargement  extends  to  the  other  portions  of  the  heart. 
The  right  ventricle  is  not  proportionately  enlarged,  unless  there 
are  concurrent  causes  which  exert  their  effect  especially  on  this 
ventricle.  Pulmonary  emphysema,  coexisting  with  aortic  lesions, 
may  render  the  enlargement  of  the  right  ventricle  as  great,  or  even 
greater,  than  that  of  the  left.  Of  the  two  auricles,  the  tendency  of 
aortic  lesions  is  to  dilate,  first  and  especially,  the  left,  but  in  some 
instances  dilatation  of  the  right  is  more  marked.  Enlargement 
associated  Vv^ith  aortic,  as  well  as  with  mitral  lesions,  is  by  no 
means  in  all  cases  proportionate,  as  regards  amount,  to  the  degree 
of  obstruction  or  regurgitation.  Enormous  enlargement  is  ob- 
served in  cases  in  which  the  contraction  or  insufficiency  is  small, 
and,  on  the  other  hand,  in  some  instances  in  which  the  obstruction 
must  have  been  extremely  great,  the  size  of  the  heart  has  been 
found  slightly  or  not  at  all  increased.  This  fact  is  illustrated  by  a 
specimen  contained  in  the  cabinet  of  the  Boston  Society  for  Medi- 
cal Improvement,  the  aortic  orifice  being  so  much  contracted  as 
hardly  to  admit  of  the  passage  of  a  small  probe.^  These  facts  here, 
as  in  the  case  of  mitral  lesions,  show  the  importance  of  concurrent 
causes  or  morbid  conditions  in  determining  the  amount  of  enlarge- 
ment of  the  heart. 

AVhen,  as  is  frequently  the  case,  mitral  and  aortic  lesions  are 
associated,  involving,  in  each  situation,  either  obstruction  or  regur- 
gitation, or  both,  the  effects  of  the  two  classes  of  lesions  are  con- 
joined. Other  things  being  equal,  the  enlargement  of  the  heart,  as 
a  whole,  is  proportionately  greater  under  these  circumstances.  The 
aortic  lesions  give  rise  to  enlargement  of  the  left  ventricle,  and 
combine  with  the  mitral  lesions  in  leading  to  enlargement  of  the 
other  portions  of  the  heart.  Among  cases  of  this  description  we 
are  likely  to  find  examples  of  excessive  augmentation  of  bulk, 
constituting  the  cor  hovinuin  of  the  old  writers. 

The  pulmonic  and  tricuspid  valves,  as  already  stated,  are  rarely 
the  seat  of  those  structural  changes  which  so  often  affect  the  valves 
of  the  left  side  of  the  heart.  Valvular  lesions,  seated  in  the  right 
side  when  they  occur,  are  usually,  but  not  invariably,  associated 
with  mitral  or  aortic  lesions,  either  separately  or  combined.  Their 
effects  upon  the  heart  are  similar  in  kind  to  those  of  lesions  seated 
in  the  left  side,  the  points  of  departure  for  enlargement  being  the 
right  auricle  in  cases  of  tricuspid  obstruction  or  regurgitation,  and 
the  right  ventricle  in  cases  of  pulmonic  contraction  or  insufficienc3\ 

'   Vide  Catalosrue. 


TRICUSPID    REGURGITATION.  131 

Examples  of  great  enlargement  of  the  right  ventricle  are  observed 
in  connection  with  congenital  contraction  of  the  pulmonary  artery. 
Tricuspid  regurgitation  occurs  not  unfrequently  without,  strictly 
speaking,  valvular  lesions  at  this  orifice.     In  certain  cases  of  dila- 
tation of  the  right  ventricle,  the  auricular  orifice  becomes  enlarged, 
the  tricuspid  valve  not  undergoing  a  corresponding  increase  in 
size.     The  consequence  is  insufficiency  of  the  valve,  or  more  or 
less  patency  of  the  orifice.     Tricuspid  regurgitation,  under  these 
circumstances,  plays  an  important  part  in  the  production  of  certain 
pathological  effects  and  symptoms  of  cardiac  disease,  viz.,  jugular 
turgescence   and    pulsation,  general   dropsy,   etc.,   which  will    be 
presently  noticed.     In  post-mortem  examinations,  valvular  insuffi- 
ciency from  this  cause  is  liable  to  be  overlooked  unless. attention 
be  directed  specially  to  the  size  of  the  orifice,  which,  in  its  normal 
condition,  should  not  greatly  exceed  four  inches  in  circumference. 
It  was  remarked  first  by  John  Hunter,  in  his  treatise  on  the  blood, 
that  the  tricuspid  valve  is  not  so  well  adapted  to  afford  complete 
protection  to  the  auricular  orifice  as  the  mitral  valve,  and  hence  he 
infers  that  it  is  less  important  for  this  orifice  to  be  protected  on  the 
right  than  on  the  left  side.     Mr.  Adams,'  of  Dublin,  and  more 
recently  and  elaborately.  Dr.  T.  W.  King,^  of  London,  have  advo- 
cated the  opinion  that  the  tricuspid  valve  is  disposed  with  special 
reference  to  regurgitation,  and  that  an  important  part  of  its  func- 
tion is  to  permit  a  retrograde  current  through  the  auricular  orifice 
when  the  right  ventricle  becomes  over-distended.     Dr.  King  bases 
his  view  of  this  "  safety-valve  function,"  as  he  terms  it,  upon  the 
connection  of  the  free  extremities  of  the  anterior  and  right  curtains 
of  the  valve  with  the  anterior  wall  of  the  ventricle,  by  means  of  the 
papillary  muscles  and  tendinous  cords.     This  connection  he  sup- 
poses to  be  such  as  to  involve  a  separation  of  these  two  curtains 
from  the  remaining  or  posterior  curtain  when  the  accumulation  of 
blood  within  the  ventricular  cavity  is  sufficient  to  over-distend  the 
ventricle  and  carry  far  outward  the  anterior  wall.     An  examina- 
tion of  a  large  number  of  hearts  with  reference  to  this  point  leads 
me  to  doubt  whether  over-distension  of  the  ventricle  produces  the 
effect  on  the  anterior  and  right  curtains  of  the  valve,  at  least  in  the 
majority  of  cases,  which  is  attributed  to  it  by  Dr.  King.     The 
arrangement  of  the  valve,  however,  is  such  that,  when  the  ventricle 

'  Dublin  Hospital  Reports,  vol.  iv. 

2  Essay  on  "  The  Safety-valve  Function  in  the  Right  Ventricle  of  the  Human 
Heart,"  by  T.  W.  King,  Guy's  Hospital  Reports,  vol.  ii. 


132      LESIONS    AFFECTING    THE    VALVES    OF    THE    HEART. 

is  distended,  it  is  highly  probable  more  or  less  regurgitation  takes 
place  at  the  commencement  of  the  ventricular  sj'stole.  But  the 
different  segments  of  the  valve  must  quickly  be  brought  into 
apposition  by  the  systolic  contraction  of  the  ventricle,  and  further 
regurgitation  prevented,  pro\iued  the  valve  be  sound  and  the 
auricular  orifice  not  enlarged.  It  is  reasonable  to  presume,  with 
Hunter,  that  the  difference  in  arrangement  between  the  tricuspid 
and  mitral  valves  is  not  without  some  important  object;  and  it  is 
not  improbable  that  the  object  is  to  permit  a  certain  amount  of 
regurgitation.  The  fact  that  the  right  auricular  orifice  is  somewhat 
larger  than  the  left  favors  this  supposition.' 

Obstruction  of  the  coronary  arteries  is  to  be  included  among  the 
pathological  effects  of  valvular  lesions  on  the  heart.  Obstruction 
arises  from  encroachment  of  masses  of  fibrinous  or  calcareous 
deposit  upon  the  mouths  of  these  arteries,  or  an  extension  of 
deposit  into  the  vessels  themselves.  The  supply  of  arterial  blood 
to  the  substance  of  the  heart  is  diminished  in  proportion  as  the 
calibre  of  the  vessels  or  their  openings  into  the  aorta  are  contracted. 
It  is  reasonable  to  infer  that  enfeebled  muscular  action  must  be  the 
immediate  result.  It  is  not  improbable  that  impaired  nutrition, 
involving  softening  and  leading  to  dilatation,  may  follow.  Accord- 
ing to  the  observations  of  Dr.  Swain,^  obstruction  of  the  coronary 
arteries  is  found  in  a  pretty  large  proportion  of  the  cases  of  fatty 
degeneration.  lie  observed  this  complication  in  twenty-five  of 
eighty  cases.  The  communications  by  anastomosis  of  the  branches 
of  the  two  coronary  arteries  not  being  very  free,  it  has  been  sup- 
posed that  obstruction  of  one  may  be  sufficient  to  give  rise  to 
important  pathological  effects.  Atrophy  of  the  muscular  substance 
of  the  heart  has  been  observed  in  connection  with  extreme  obstruc- 
tion from  the  deposit  of  atheroma  or  calcareous  deposit  within 
these  arteries.  Formerly  the  paroxysms  of  severe  pain  which 
occur  during  the  progress  of  some  cases  of  organic  disease  of  the 
heart,  constituting  the  superadded  affection  known  as  angina  pec- 
toris^ were  attributed  to  coronary  obstruction  ;  but  clinical  observa- 
tion has  abundantly  shown  this  association  to  be  by  no  means 
constant. 

As  symptoms  referable  directly  to  the  heart  may  be  noticed,  pain, 

'  The  discussion  of  this  subject  belongs  to  physiology.  The  reader  will  find 
some  remarks  advocating  the  view  here  taken  in  the  appendix  to  Hope  on  Diseases 
of  the  Heart,  Am.  ed.,  p.  546. 

2  Med.-Chir.  Trans.,  vide  Bellingham,  op.  cit. 


PAIN    AND    PALPITATION.  133 

palpitation,  abnormal  changes  of  the  pulse,  turgescence  of  the  veins, 
and  venous  pulsation. 

Pain. — Exclusive  of  paroxysms  ofsuffering,  frequently  extremely 
severe,  constituting  the  affection  superadded  to  certain  cases  of  or- 
ganic disease  of  the  heart  known  as  angina  pectoris  (an  affection  to 
be  considered  hefeafter),  pain  is  not  a  prominent  symptom  of  val- 
vular lesions.  In  the  majority  of  cases,  this  symptom  is,  in  fact, 
wanting.  Absence  of  pain  is  the  rule,  but  occasionally  patients 
complain  of  painful  sensations,  referred  to  the  priecordia.  A  sense 
of  constriction,  uneasiness,  or  undefinable  distress,  is  oftener  met 
with  than  actual  pain.  These  sensations  are  not  distinctive  of 
organic  disease ;  they  are  quite  as  likely  to  occur  in  connection 
with  merely  functional  disorder  of  the  heart.  When  present,  they 
do  not  indicate  the  particular  seat  of  the  lesions,  but  it  is  undoubt- 
edly true  that  they  occur  more  rarely  in  connection  with  mitral 
than  with  aortic  lesions.  This  statement  will  be  found  to  hold 
good  equally  with  respect  to  paroxysms  of  angina  pectoris.  When 
the  existence  of  valvular  lesions  is  determined,  by  means  of  phj'si- 
cal  signs  presently  to  be  considered,  the  absence  of  pain,  and,  it 
may  be  added,  tenderness  or  soreness  of  the  prascordia,  is  of  some 
weight  in  determining  that  the  affection  of  the  valves  does  not 
involve  existing  inflammation  or  endocarditis.  But,  as  will  be 
seen  hereafter,  pain,  tenderness,  or  soreness  are  by  no  means  always 
present  when  endocardial  inflammation  exists,  so  that  absence  of 
these  symptoms  is  not  proof  against  the  existence  of  endocarditis. 

Palpitation. — A  person  in  health  is  not  conscious  of  the  action  of 
the  heart  except  when  it  is  excited  by  exercise,  mental  emotion,  or 
some  other  transient  cause.  The  abnormal  power  or  violence  of 
this  action  in  some  cases  of  organic  disease,  however,  renders  it 
perceptible  to  the  patient.  It  may  force  itself  on  his  attention,  and 
occasion  annoyance  or  suffering,  the  action  being,  in  some  instances, 
simply  more  or  less  intense,  and  in  others,  at  the  same  time,  irre- 
gular or  intermitting.  The  consciousness  of  an  undue  force  of 
impulsion  is  by  no  means  a  constant  symptom  of  valvular  affec- 
tions. It  does  not  occur  till  the  heart  becomes  enlarged  as  a  result 
of  these  affections.  It  is,  in  fact,  due,  not  directly  to  the  lesions  of 
the  valves  or  orifices,  but  to  the  hypertrophy  to  which  they  give 
rise.  When  the  patient  complains  of  the  beating  of  the  heart,  the 
impulse  is  found,  on  applying  the  hand  over  the  pra3Cordia,  to  be 


134-      LESI0X3    AFFECTING    THE    VALVES    OF    THE    HEART. 

abnormally  forcible.  Portions  of  the  dress  or  body  are  visibly 
moved  by  the  violence  of  the  action.  But  the  patient  often  does 
not  complain  of  this  symptom,  and  may  not  appear  even  to  notice 
it,  when  to  the  observer  it  is  strongly  marked.  It  is  not  unusual 
for  patients  to  say  that  they  have  never  experienced  palpitation, 
when  the  action  of  the  heart  is  perceived  by  the  hand,  applied 
over  the  priecordia,  to  be  extremely  violent  aad  irregular.  The 
explanation  of  this  is,  the  abnormal  force  having  been  developed 
gradually  and  imperceptibly,  the  mind  has  become  habituated  to  it, 
and  is  unconscious  of  it,  at  least  unless  the  attention  be  directed  to 
it.  Palpitation,  therefore,  may  be  present  as  an  objective  when  it 
is  wanting  as  a  subjective  symptom.  Hence,  also,  the  incon- 
venience which  it  occasions  does  not  alwaj^s  correspond  with  the 
degree  in  which  it  actually  exists.  Other  things  being  equal,  the 
increased  violence  of  the  heart's  action  is  proportionate  to  the 
amount  of  hypertrophy,  and  especially  hypertrophy  of  the  left 
ventricle. 

The  consciousness  of  undue  violence  or  of  irregularity  of  the 
heart's  action,  exclusive  of  other  circumstances,  is  not  significant  of 
organic  disease.  On  the  contrary,  if  the  patient  complain  of  this  as 
a  prominent  symptom,  the  presumption  is  that  organic  disease  does 
not  exist.  Palpitation  from  functional  disorder  always  occasions 
great  uneasiness,  and  generally  intense  anxiety  and  alarm.  It  is 
quite  otherwise  with  palpitation  incident  to  organic  disease.  It  is 
surprising  how  insensible  patients  frequently  are  to  the  excessive 
force  and  great  irregularity  of  the  action  of  the  heart,  when  due  to 
structural  affections,  and  how  indifferent  they  often  are  when  con- 
scious of  palpitation.  The  contrast,  in  this  respect,  between  cases 
of  organic  disease  and  those  of  merely  functional  disorder  is  very 
striking.  Other  points  serve  to  distinguish  functional  palpitation 
from  that  due  to  organic  disease.  The  latter  is  less  violent,  but, 
to  a  greater  or  less  extent,  constant,  while  the  former  occurs  in 
paroxysms,  in  the  intervals  of  which  the  heart  is  tranquil.  Palpi- 
tation from  organic  disease,  increased  beyond  its  habitual  amount, 
is  occasioned  generally  by  some  obvious  cause,  and  more  especially 
by  muscular  exercise.  Functional  palpitation  occurs  often  when  it 
cannot  be  traced  to  any  exciting  cause,  and  is  more  likely  to  occur 
when  the  patient  is  at  rest  than  when  engaged  in  active  exertion. 
The  former  takes  place  more  frequently  in  the  daytime,  the  latter 
during  the  night.     These  and  other  points  pertaining  to  the  differ- 


PALPITATION    AND    THE    PULSE.  lo5 

ential  diagnosis  will  be  considered  more  fully  in  treating  of  func- 
tional disorders  of  the  heart. 

As  regards  the  relations  of  palpitation  to  the  different  valvular 
lesions,  undue  violence  of  the  heart's  action  occurs  more  frequently, 
and,  as  a  rule,  is  more  marked  in  cases  of  aortic  than  in  cases  of 
mitral  lesions.  This  is  owing  to  the  fact  that  the  former,  more 
than  the  latter,  tend  to  give  rise  to  hj^pertrophy  of  the  left  ven- 
tricle. The  violence  of  the  impulse,  of  course,  depends  on  the 
amount  of  enlargement  bj^  hypertrophy  rather  than  by  dilatation, 
and  on  the  activity  of  the  muscular  contractions.  The  patient  is 
more  likely  to  perceive  and  suffer  from  the  violence  of  the  heart's 
action  if  the  hypertrophy  has  been  developed  rapidly  than  if  its 
progress  has  been  very  gradual.  The  irregularity,  of  which  the 
patient  may  or  may  not  be  conscious,  depends,  in  a  great  measure 
at  least,  on  the  variations  in  the  quantity  of  blood  delivered  to  the 
cavities,  in  consequence  of  the  interruption  to  the  currents  by  the 
obstructive  or  regurgitant  lesions.  Irregularity  of  action  due  to 
these  causes  will  be  considered  in  connection  with  the  pulse. 

Pulse. — The  characters  of  the  pulse  are  often  of  considerable 
assistance  in  determining  the  situation,  nature,  and  extent  of  lesions 
affecting  the  valves  arid  orifices  of  the  heart.  The  abnormal  varia- 
tions, which  are  important  to  be  considered  with  reference  to  the 
points  just  mentioned,  are  its  size  and  strength  as  compared  with 
the  heart's  impulse,  its  rhythm,  the  equality  or  inequality  of  suc- 
cessive beats,  its  quickness  or  slowness,  the  duration  of  the  move- 
ment of  the  artery  under  the  finger,  etc.  The  frequency  of  the 
pulse,  although  important  as  representing  the  general  condition  of 
the  circulation  and  the  state  of  the  vital  forces,  has  no  special 
significance  as  regards  valvular  disease. 

In  mitral  lesions  attended  by  regurgitation,  the  size  and  strength 
of  the  pulse  are  diminished  in  proportion  to  the  quantity  of  blood 
driven  backwards,  by  the  systolic  contraction  of  the  left  ventricle, 
into  the  left  auricle.  If  a  small  quantity  only  regurgitates,  the 
pulse  may  still  retain  considerable  volume  and  force ;  but  if  the 
amount  of  regurgitation  be  large,  the  pulse  is  notably  weak  and 
small.  The  weakness  and  smallness  of  the  pulse  are  in  contrast 
with  the  impulse  of  the  heart,  as  felt  by  the  hand  applied  over  the 
prtecordia,  provided  the  left  ventricle  be  hypertrophied  and  tlie 
action  of  the  heart  vigorous.  The  pulse  may  be  regular,  but  often, 
in  an  advanced  stage  of  the  affection,  its  rhythm  is  disturbed;  it 


136      LESIONS    AFFECTING    THE    VALVES    OF    THE    HEAET, 

becomes  irregular  or  intermitting.  This,  however,  is  due,  not 
directly  to  the  regurgitation,  but  to  the  condition  of  the  muscular 
walls  of  the  organ.  Inequality  of  the  pulse,  that  is,  variation  of 
successive  beats  as  respects  size,  force,  etc.,  is  less  characteristic  of 
mitral  regurgitant  lesions  than  of  those  attended  by  obstruction. 
The  pulse  in  cases  of  mitral  regurgitation  is  not  unfrequently 
quick  or  vibratory.  It  presents  this  quality  when  the  regurgita- 
tion is  not  excessive,  and  the  left  ventricle  is  moderately  hyper- 
trophied.  The  frequency  here,  as  in  the  other  varieties  of  valvular 
lesions,  depends  on  the  vital  condition  of  the  heart. 

Mitral  obstructive  lesions  equally,  but  in  a  different  manner, 
involve  diminution  of  the  size  and  strength  of  the  pulse.  In 
regurgitation,  the  pulse  is  rendered  small  and  weak  by  the  deduc- 
tion of  the  blood  which  regurgitates  from  the  quantity  which 
would  otherwise  be  propelled  into  the  aorta  with  each  systole.  In 
obstruction,  the  blood  not  passing  from  the  left  auricle  with  suffi- 
cient freedom,  the  left  ventricle  fails  to  receive  the  quantity  which 
should  be  propelled  into  the  aorta.  In  the  one  case,  the  left  ven- 
tricle is  abundantly  supplied,  but  it  is  not  capable  of  conveying  all 
its  contents  into  the  arterial  system  in  consequence  of  the  insuffi- 
ciency of  the  mitral  valve ;  in  the  other  case,  the  supply  to  the  left 
ventricle  is  deficient,  and  the  blood  accumulates  in  the  left  auricle 
and  pulmonary  vessels.  In  both  cases  the  effect  is  the  same  so  far 
as  regards  the  lessened  quantity  of  blood  propelled  into  the  aorta, 
and  hence  in  both  alike  there  occurs  abnormal  diminution  of  the 
size  and  strength  of  the  pulse.  The  pulse,  under  these  circum- 
stances, as  in  cases  of  mitral  regurgitation,  is  sometimes  quick, 
vibratory,  or  jerking.  Mitral  contraction,  when  extreme,  renders 
the  pulse  not  only  small  and  weak,  but  often  irregular,  intermitting, 
and  unequal.  The  latter  variations  are  observed  especially  when 
the  pulse  is  at  the  same  time  frequent.  The  inequality  depends  on 
the  varying  quantity  of  blood  which  passes  from  the  auricle  to  the 
ventricle  between  the  successive  sj^stolic  contractions  of  the  ven- 
tricles. WliQn  the  orifice  is  much  obstructed,  various  circumstances 
prevent  an  equal  supply  of  blood  to  the  ventricle  prior  to  the 
ventricular  systoles,  and  in  proportion  to  the  quantity  of  blood 
propelled  into  the  aorta,  other  things  being  equal,  will  be  the  size 
.and  force  of  the  pulse.  When,  from  any  cause,  the  supply  of  blood 
preceding  the  ventricular  sj^stole  is  less  than  usual,  the  pulse,  which 
represents  the  systole  of  the  left  ventricle,  is  unusually  small  and 
weak.     Under  these  circumstances,  the  action  of  the  heart  is  often 


IRREGULAR    AND    INTERMITTENT    PULSE.  187 

increased  in  an  irregular  manner.  A  greater  deficiency  of  blood 
than  usual  causes  the  ventricle  to  contract  for  several  beats  with 
more  frequency,  as  if  to  compensate  by  the  number  of  systolic 
movements  for  the  deficient  supply  of  blood ;  hence,  it  is  not  un- 
usual after  several  regular  beats  of  the  pulse,  having  a  certain 
volume  and  strength,  for  a  series  of  rapid  beats  to  ensue,  which  are 
notably  small  and  weak.  As  remarked  by  Dr.  Adams,  "  it  appears 
as  if  there  were  two  pulses,  one  slow  and  deliberate  for  two  or 
three  beats,  succeeded  by  three  or  four  rapid  and  indistinct  pulsa- 
tions."^ Intermittency  of  the  pulse  may  represent  intermittency  of 
the  heart's  action,  but  it  is  sometimes  observed  when  there  is  not  a 
corresponding  interruption  in  the  heart's  impulse.  The  apex-beats 
may  be  felt  by  the  hand  over  the  pr^cordia  to  take  place  in  regu- 
lar succession,  while  the  pulse  is  found  to  intermit  more  or  less 
frequentl3^  This  occurs  in  some  cases  of  mitral  obstruction,  the 
explanation  being  that  the  quantity  of  blood  delivered  from  the 
auricle  to  the  ventricle,  through  the  contracted  orifice,  is  at  times 
insufficient  for  the  wave  through  the  remote  arteries  to  be  perceived 
by  the  touch.  The  beats  which,  under  these  circumstances,  are  lost 
at  the  radial  artery,  may  be  distinguishable  at  an  artery  larger  in 
size  and  nearer  the  heart,  viz.,  the  carotid.  Intermittency  of  the 
pulse,  it  must  be  recollected,  is  a  peculiarity  of  the  circulation  in 
some  persons  in  health.  An  intermission,  or  the  loss  of  a  beat, 
occurs  more  or  less  frequently,  the  person  not  being  conscious  of 
its  occurrence.  It  is  not,  therefore,  intrinsically  a  symptom  of  dis- 
ease. It  is  a  curious  fact  that  in  persons  who  present  this  idiosyn- 
crasy the  pulse  ceases  to  be  intermittent  in  disease  attended  by 
febrile  movement.  A  reappearance  of  the  intermissions,  under 
these  circumstances,  is  evidence  of  the  return  of  health.  Weak- 
ness, smallness,  and  irregularit}^,  as  well  as  intermittency  and  even 
inequality,  it  is  to  be  borne  in  mind,  are  not  distinctive  of  mitral 
or  other  valvular  lesions.  All  these  characters  of  the  pulse  may 
occur  in  cases  of  enlargement  or  fatty  degeneration  uncomplicated 
with  lesions  of  the  valves  or  orifices.  All  may  occur,  moreover, 
in  merely  functional  disorder  of  the  heart.  A  distinguishing  point 
pertaining  to  the  latter  is,  that  they  occur  only  during  paroxysms 
of  palpitation  presenting  the  distinctive  features  of  palpitation  from 
nervous  disorder,  while,  occurring  in  connection  with  valvular 
lesions,  they  are  either  constant  or  frequently  recurring,  and  un- 

'  Dublin  Hospital  Reports,  vol.  iv.     From  Bellingliara,  op.  cit. 


138      LESIOXS    AFFECTING   THE    VALVES    OF    THE    HEART. 

attended  by  the  features  whicli  distinguish  functional  palpitation. 
It  is  also  to  be  borne  in  mind  that  in  cases  of  mitral  obstruction, 
provided  the  contraction  of  the  orifice  be  not  extremely  great,  the 
pulse  may  present  sufficient  size  and  strength,  and  it  may  be  regu- 
lar and  equal.  It  becomes  irregular,  intermittent,  and  unequal  more 
especially  at  an  advanced  stage  of  disease,  when  great  dilatation 
and  weakness  of  the  muscular  walls  are  superadded  to  the  valvular 
affection.  It  follows  from  these  remarks  that  the  diagnostic  value 
of  the  abnormal  variations  of  the  pulse  which  have  been  mentioned, 
depends  not  on  the  characters  intrinsically,  but,  in  a  great  measure, 
on  the  associated  circumstances.  Considered  alone,  their  import  is 
not  distinctive  of  the  nature,  situation,  or  existence  of  organic  dis- 
ease, but  taken  in  connection  with  other  symptoms,  and  with  phy- 
sical signs,  they  often  supply  important  information.  Thus,  the 
existence  of  mitral  lesions  having  been  ascertained  by  means  of 
signs  which  are  sufficiently  distinctive  for  the  diagnosis,  the  charac- 
ters of  the  pulse  which  have  been  noticed  will  assist  in  determining 
whether  the  lesions  are  obstructive  or  regurgitant ;  but  they  afford 
more  aid  in  estimating  the  extent  to  whicb  either  regurgitation  or 
obstruction  interferes  with  the  cardiac  circulation.  As  regards  the 
differential  diagnosis  between  regurgitation  and  obstruction,  the 
pulse  is  more  likely  to  be  unequal,  irregular,  and  intermitting  in 
the  latter  than  in  the  former,  irrespective  of  that  degree  of  dilatation 
and  weakness  of  the  heart  which  may  induce  these  characters  with 
or  without  valvular  lesions.    The  amount  of  obstruction  or  reo-uro-i- 

O         O 

tation  is  represented  by  the  smallness  and  weakness  of  the  pulse, 
the  more  these  characters  are  in  contrast  with  the  strength  of  the 
heart's  impulse  or  felt  by  the  hand  in  the  prascordia.  It  will  be 
recollected  that  mitral  obstructive  and  regurgitant  lesions  are  not 
unfrequently  combined.  The  symptomatic  phenomena  referable  to 
the  pulse  will,  of  course,  be  more  marked  in  such  cases. 

Aortic  lesions  giving  rise  to  obstruction  are  not  characterized  by 
a  pulse  weakened  in  proportion  to  the  diminished  quantity  of  blood 
propelled  from  the  left  ventricle.  Even  when  the  contraction  of 
the  orifice  is  great,  the  pulse  generally  retains  considerable  force. 
In  an  instance  in  which  the  orifice  was  reduced  to  the  size  of  a 
quill,  the  pulse  was  neither  small  nor  weak  in  a  marked  degree. 
This  fact,  which  at  first  view  may  seem  inconsistent,  is  intelligible 
when  it  is  considered  that  a  primary  effect  of  aortic  obstruction  is 
hypertrophy  of  the  left  ventricle.  The  increased  muscular  power 
of  this  ventricle  thus  in  a  measure  compensates  for  the  reduction 


EFFECT    OF    AORTIC    LESIONS    ON   THE    PULSE.  189 

in  size  of  the  aortic  orifice.'  Moreover,  the  arteries  are  not  unfilled 
to  tlie  same  extent  as  in  cases  of  great  mitral  obstruction  and 
regurgitation,  and  the  momentum  communicated  by  the  hypertro- 
phied  ventricle  to  the  column  of  blood  contained  in  the  arteries 
may  be  sufficient  to  produce  a  pretty  strong  pulsation  of  the  arterial 
trunks,  even  when  obstructive  aortic  lesions  exist  to  a  considerable 
extent.  Nevertheless,  in  cases  of  extreme  contraction  (to  which 
reference  has  been  made),  in  which  the  orifice  has  been  found 
scarcely  to  admit  a  small  probe,  the  obstruction  is  too  great  to 
admit  of  compensation,  and  the  pulse,  under  these  circumstances, 
is  small  and  weak.  In  cases  of  aortic  obstruction,  when  enlarge- 
ment of  the  heart  has  ensued,  and  especially  when  the  muscular 
power  of  the  organ  is  much  diminished,  the  pulse  may  become 
irregular,  intermitting,  and  unequal.  These  deviations  occur  alike 
in  aortic  and  mitral  lesions  at  an  advanced  period  of  the  disease. 
They  occur,  however,  less  frequently,  at  a  later  period,  and  in  a 
less  marked  degree,  in  cases  of  aortic  obstruction  than  in  cases  of 
either  mitral  obstruction  or  regurgitation.  Irregularity  and  in- 
equality are  thus,  in  some  measure,  diagnostic  of  lesions  affecting 
the  mitral  orifice  as  contrasted  with  those  affecting  the  aortic  ori- 
fice ;  but  it  is  to  be  borne  in  mind  that  they  occur  in  cases  of 
dilatation,  fatty  degeneration,  etc.,  uncomplicated  with  any  affection 
of  the  valves  or  orifices.  "When  the  amount  of  aortic  obstruction 
is  sufficient  to  affect,  in  a  marked  degree,  the  size  and  force  of  the 
pulse,  the  impulse  felt  in  the  prcecordia  may  be  abnormally  strong, 
owing  to  hypertrophy  of  the  left  ventricle.  It  is  especially  in  cases 
of  this  description  that  a  marked  contrast  between  the  pulse  and 
the  heart's  impulse  is  observed. 

Aortic  lesions  giving  rise  to  regurgitation,  if  the  regurgitant  cur- 
rent be  considerable,  are  characterized  by  a  pulse  which  is  in  some 
measure  diagnostic.  When  the  aortic  valves  are  sufficient,  the 
column  of  blood  contained  in  the  arteries  is  supported  by  them, 
after  the  systolic  contraction  of  the  ventricle,  and  the  elastic  recoil 
of  the  arterial  coats  contributes  in  propelling  the  blood  in  its  out- 

'  Dr.  Blakiston  conjectures  that  an  additional  mode  of  compensation  consists 
in  a  prolongation  of  the  systolic  contraction  when  considerable  aortic  contraction 
exists,  the  blood  (quoting  his  language)  being  "  gradually  squeezed  through  the 
contracted  orifice."  (Practical  Observations  on  certain  Diseases  of  the  Chest,  etc.,  Am. 
ed.,  p.  225.)  The  reader  will  find  cited,  in  connection  with  this  subject,  in  that 
work,  several  cases  illustrating  extreme  aortic  contraction,  in  which  the  symptoms 
of  cardiac  disease  were  very  slightly  manifested. 


14:0      LESIONS    AFFECTIXG    THE    VALVES    OF    THE    UEAKT. 

ward  current.  But  if  the  valves  are  insufficient,  the  column  of 
blood  being  incompletely  supported  after  the  ventricular  sj'stole,  a 
quantity,  greater  or  less,  according  to  the  extent  of  the  insufficiency 
of  the  valves,  flows  backwards  into  the  ventricle,  and  the  recoil  of 
the  arterial  coats  acts  alike  in  producing  an  onward  and  a  regur- 
gitant current,  so  that  when  the  contraction  of  the  left  ventricle 
takes  place,  the  blood  propelled  into  the  aorta  meets  a  regurgitant 
instead  of  an  onward  current.  Clinical  observation  shows  that 
under  these  circumstances,  as  first  pointed  out  by  Dr.  Corrigan,  of 
Dublin,  the  pulse  is  notably  quick  and  short,  that  is  to  s2lj  jei-king. 
The  artery  strikes  the  finger  suddenly  and  often  with  considerable 
force,  and  appears  instantly  to  recede.  This  has  also  been  called  a 
"  collapsing  pulse."  It  occurs,  as  a  rule,  in  cases  of  aortic  lesions 
with  considerable  insufficiency,  and  the  jerking  or  collapsing  feature 
is  usually  strongly  marked.  It  is  not,  however,  a  symptom  so  dis- 
tinctive of  aortic  regurgitation,  as  it  appears  to  be  considered  by  Dr. 
Corrigan  and  others.  Clinical  observation  shows  that  the  pulse  is 
sometimes  jerking  in  cases  of  mitral  obstruction  and  regurgitation, 
the  aortic  valves  being  unaffected.  But  it  is  undoubtedly  true  that 
the  symptom  is  much  oftener  present  and  more  strongly  marked  in 
cases  of  aortic  regurgitation.  It  is  not  a  symptom  of  aortic  obstruc- 
tion, and  inasmuch  as  the  physical  signs  enable  the  diagnostician 
to  determine  the  existence  of  lesions  affecting  the  valves  or  orifice 
of  the  aorta,  it  is  a  symptom  of  importance  as  indicating  that  the 
lesions  here  situated,  are  of  a  kind  to  permit  regurgitation.  Taken 
alone,  it  is  certainly  not  reliable  as  evidence  of  the  presence  of 
aortic  lesions,  but  these  having  been  ascertained,  it  aids  in  discrimi- 
nating between  obstructive  and  regurgitant  lesions,  or  rather  it  indi- 
cates the  existence  of  the  latter  either  with  or  without  the  former. 

Visible  pulsation  of  arterial  trunks  superficially  situated,  such 
as  the  subclavian,  carotid,  temporal,  brachial,  radial,  etc.,  is  a 
symptom  somewhat  characteristic  of  aortic  regurgitation.  If  the 
insufficiency  of  the  valve  be  great,  an  effect  of  the  collision  of  the 
retrograde  diastolic  current,  and  the  onward  systolic  current  in  the 
vessels,  is  to  cause  the  latter,  as  it  were,  to  be  "  suddenly  thrown 
from  their  bed,  bounding  up  under  the  skin."  The  visible  pulsa- 
tion is  due  not  alone  to  the  diastolic  movements  of  the  coats  of  the 
vessels,  but  to  the  locomotion  of  the  arteries.  They  "  sometimes 
appear  like  worms  under  the  skin,  wriggling  into  tortuous  lines 
at  each  pulse."'     The  connection  of  this  symptom  with  aortic  re- 

■  Dr.  Williams.     Bellingliam,  op.  cit. 


VISIBLE    AND    DEFINED    PULSE.  141 

gurgitation,  was  first  pointed  out  by  Dr.  Corrigan.^  It  is  by  no 
means  a  symptom  which  belongs  exclusively  in  this  connection. 
It  is  observed  in  a  marked  degree,  not  unfrequeutly,  in  thin  per- 
sons when  the  arteries  have  become  rigid  or  calcareous,  with  or 
without  cardiac  disease.  In  a  moderate  degree  it  is  sufficiently 
common  in  various  pathological  associations.  But  it  is  a  symptom 
usually  present  in  cases  in  which  considerable  regurgitation  takes 
place,  and  is  generally  strongly  marked.  Dr.  Walshe  states  that 
no  well-marked  case  of  aortic  regurgitation  has  ever  fallen  under 
his  notice,  in  which  visibleness  in  the  superficial  pulses  was  not 
more  or  less  present,  and  that  he  has  never  observed  highly-marked 
and  extensive  visible  pulsation  without  aortic  regurgitant  disease.^ 
The  coexistence  of  considerable  mitral  obstruction  with  regurgita- 
tion, does  not,  as  supposed  by  Hope,  prevent  this  symptom  from 
being  present,  at  least  in  all  cases.  Taken  in  conjunction  with  the 
signs  which  establish  the  diagnosis  of  aortic  lesions,  it  concurs  with 
the  jerking  pulse,  in  signifying  that  the  lesions  are  of  a  nature  to 
render  the  valve  insufficient.'', 

Another  symptom  pertaining  to  the  pulse,  has  been  pointed  out 
b}'  Dr.  Henderson,  as  significant  of  aortic  regurgitation,  viz :  prolon- 
gation of  the  interval  between  the  pulsation  of  the  radial  artery  and 
the  heart's  impulse.^  The  interval,  according  to  Dr.  Henderson,  is 
sometimes  so  much  lengthened  "  that  the  heart  and  the  radial  artery 
seem  to  beat  with  a  distinct  alternation."  The  rationale  of  this 
symptom  is  intelligible,  in  view  of  the  conflicting  currents  within 
the  large  vessels  which  have  been  referred  to  in  connection  with 
the  production  of  a  jerking  pulse,  and  visible  pulsation  of  the  arte- 
ries. Some  observers  have  been  led  to  doubt  the  frequent  occur- 
rence of  this  symptom.  That  it  characterizes  certain  cases  in  which 
the  regurgitation  is  excessive,  is  not  to  be  denied.  In  a  case  of 
mitral  and  aortic  regurgitation,  with  great  hj^pertrophic  enlarge- 
ment, which  came  under  my  observation,  the  interval  between 
the  apex-beat  and  the  beat  of  the  radial  artery,  was  longer  than 
that  between  the  first  and  second  sounds  of  the  heart.  The  radial 
pulse  was,  in  fact,  in  much  closer  relation  to  the  diastole  than  to  the 
systole.  The  interval  between  the  apex-beat  and  the  pulsation  of 
the  carotid  artery,  was  less,  being  about  the  same  as  exists  normally 
between  the  apex-beat  and  the  radial  pulse.   The  visible  movements 

'  Edinb.  Med.  and  Surg.  Journ.,  voL  x'svii.  1832. 

2  Op.  cit.,  English  second  edition,  p.  265. 

3  Edinburgh  Monthly  Journal,  Ma^,  1843. 


142      LESIONS    AFFECTING   THE    VALVES    OF    THE    HEART. 

of  the  arteries,  and  the  jerking  character  of  the  pulse  were  strongly 
marked  in  this  case.''  The  sphygmoscope^  recently  devised  by  Dr. 
Scott  Alison,  of  London,  is  admirably  adapted  to  illustrate  the  rela- 
tive occurrence  of  the  apex-beat  and  the  arterial  pulse,  in  different 
situations. 

Turgescence  of  the  Veins  and  Venous  Pulsation. — Abnormal  fulness 
of  the  veins  occurs  whenever  an  obstacle  exists  to  the  free  entrance 
of  blood  into  the  right  auricle.  An  obstacle  exists,  when,  from  any 
cause,  the  right  auricle  is  already  full,  or  distended  with  blood. 
Various  abnormal  conditions  involve  this  result.  The  most  direct 
and  efficient  causative  condition  is  contraction  of  the  tricuspid  ori- 
fice. But  this  is  exceedingly  rare;  so  much  so,  that  the  probabi- 
lities of  its  existence  in  a  given  case  of  distension  of  the  right 
auricle,  are  hardly  sufficient  for  it  to  be  taken  into  account.  Tri- 
cuspid regurgitation  is  another  condition  leading  directly  and  effi- 
ciently to  the  result.  This,  although  probably  not  of  very  frequent 
occurrence,  at  least  in  an  abnormal  degree,  exists  much  oftener 
than  tricuspid  contraction.  The  explanation  of  distension  of  the 
right  auricle,  when,  from  insufficiency  of  the  tricuspid  valve,  a  por- 
tion of  the  contents  of  the  right  ventricle  is  driven  backward  with 
each  systole,  is  obvious.  Dilatation  of  the  auricle  follows  sooner 
or  later.  Lesions  affecting  the  valve  or  orifice  of  the  pulmonary 
artery  also  induce  distension  and  dilatation  of  the  right  auricle, 
exerting  an  effect  primaril}'-  on  the  right  ventricle.  Contraction 
and  insufficiency  here  situated,  have  been  seen  to  be  as  infrequent 
as  tricuspid  obstruction,  excepting  instances  of  congenital  lesions. 
In  the  affections  developed  after  birth,  therefore,  these  are  to  be 
excluded  as  probable  conditions  giving  rise  to  venous  turgescence. 
Distension  and  dilatation  of  the  auricle,  however,  occur  irrespective 
of  lesions  affecting  either  the  tricuspid  or  pulmonic  orifice.  They 
occur,  as  has  been  seen,  in  connection  with  mitral  and  aortic  lesions 
which  involve  either  obstruction  or  regurgitation,  separately  or 
combined.  The  right  ventricle  in  these  cases  first  becomes  over- 
distended  and  enlarged,  and,  consecutively,  distension  and  dilata- 
tion of  the  right  auricle  follow.  Turgescence  of  the  superficial 
veins  is  therefore  observed,  not  alone  in  cases  of  tricuspid  and 
pulmonic,  but  also  in  cases  of  mitral  and  aortic  lesions  when  the 
latter  have  led  to  over-repletion  and  enlargement  of  the  riglit  side 
of  the  heart.     It  is  equally  a  symptom  of  the  latter  when  not  in- 

'  Case  of  Ilart,  riivate  Records,  vol.  x.  p.  586. 


VENOUS    TUEGESCEjS'CE.  143 

duced  bj  valvular  lesions.  Obstruction  to  the  pulmonary  circula- 
tion from  any  cause,  for  example,  from  empli^'sema  of  the  lungs, 
occasions  an  undue  accumulation  of  blood  within  the  right  ven- 
tricle and  auricle,  leading  perhaps  to  enlargement,  and  a  conse- 
quent obstacle  to  the  free  escape  of  blood  from  the  systemic  veins. 
Finally,  pressure  on  the  vena  cava  by  an  intra-thoracic  tumor  pro- 
duces obstruction  and  venous  turgescence.  Thus,  marked  fulness 
of  the  veins  of  the  head  and  neck  is  observed  in  some  cases  of 
aneurism  of  the  arch  of  the  aorta.  As  a  symptom,  then,  this  is  not 
distinctive  in  itself  of  cardiac  disease,  nor  when  it  proceeds  from 
the  latter,  does  it  point  to  the  seat,  or  even  denote  the  existence 
of  lesions  of  the  valves  or  orifices.  Exclusive  of  the  cases  in  which 
it  is  an  immediate  effect  of  extra-cardiac  obstruction,  it  simply 
shows  that  the  right  auricle  is  either  dilated  or  over-distended. 

Venous  turgescence  may  be  apparent  whenever  the  superficial 
vehis  are  visible,  but  it  is  usually  most  conspicuous  on  the  neck,  in 
the  jugulars,  and  the  venous  branches  communicating  with  them. 
In  some  instances  of  extreme  turgescence  the  vessels  are  developed 
so  as  to  present  a  varicose  appearance.  These  veins  may  be  ha- 
bitually full  and  dilated,  as  they  are  seen  to  be  temporarily  during 
prolonged  expiratory  efforts  in  singing,  playing  on  wind  instru- 
ments, straining,  and  in  paroxysms  of  spasmodic  cough.  If  the 
cardiac  obstruction  be  considerable,  when  pressure  is  made  on  a 
vein  high  on  the  neck,  the  vessel  remains  distended  below  the 
point  of  pressure,  and  may  be  refilled  after  the  contents  of  the 
vessel  have  been  pressed  backward  by  the  finger,  showing  not  only 
a  resistance  to  the  gravitation  of  the  blood,  but  a  reflux  current. 

Although,  intrinsically,  this  symptom  appears  wanting  in  precise 
diagnostic  significance,  taken  in  connection  with  the  physical  signs 
which  establish  the  nature  and  seat  of  organic  lesions  of  the  heart, 
it  possesses  considerable  value.  If  it  proceed  from  lesions  situated 
at  the  tricuspid  or  pulmonic  orifices,  the  concurrent  signs  will  show 
the  existence  of  these  lesions,  and  the  degree  of  venous  turgescence 
will  be,  to  some  extent,  an  index  of  the  extent  to  which  they  occa- 
sion immediate  obstruction.  If,  on  the  other  hand,  it  proceed  (as  it 
does  in  the  vast  majority  of  cases)  from  aortic  or  mitral  lesions,  the 
signs  enable  us  to  localize  these,  and  the  turgescence  is  then  evi- 
dence, and  its  degree  in  some  measure  a  criterion,  of  the  effect 
which  they  have  produced  on  the  right  side  of  the  heart.  It  shows 
that  the  mitral  or  aortic  lesions  involve  an  amount  of  obstruction 
which  will  be  likely  to  lead  to  enlargement  of  the  right  auricle  and 


144      LESIONS    AFFECTING    THE    VALVES    OF    THE    HEART. 

ventricle,  if  it  have  not  already  taken  place.  It  shows  also  an 
effect  on  the  sj'stemic  circulation  which  involves  a  liability  to  other 
effects  dependent  on  it,  viz.,  dropsy,  extravasation  of  blood,  and 
hemorrhage.  In  these  points  of  view  it  is  a  symptom  which  de- 
serves attention  in  the  examination  of  patients  affected  with  cardiac 
disease.  It  is,  of  course,  understood  that  the  value  of  this  symptom, 
in  its  relation  to  disease  of  the  heart,  depends  on  the  absence  of 
extra-cardiac  conditions,  such  as  emphysema,  aneurism,  &c.,  which 
may  give  rise  to  it.  Careful  examination  will  generally  enable  the 
diagnostician  either  to  exclude  these  conditions  or  to  ascertain 
their  presence  in  individual  cases. 

Yenous  pulsation  is  a  diastolic  movement  of  the  veins,  visible, 
and  sometimes  even  appreciable  by  the  touch,  occurring,  in  gene- 
ral, sj^nchronousl}^  with  the  ventricular  systole  of  the  heart.  The 
movement  is  due  to  a  retrograde  current  or  impulse  communicated 
to  the  blood  contained  in  the  veins  by  the  contraction  of  the  right 
ventricle.    It  is  to  be  disting-uished  from  the  movements  occasioned 

O 

by  respiration,  with  which  every  one  is  familiar,  and  also  from 
those  communicated  by  subjacent  arteries.  With  the  latter  it  is 
liable  to  be  confounded,  unless  care  be  taken  to  avoid  it.  It  may 
be  avoided  by  pressing  the  blood  from  the  pulsating  vein,  and 
ascertaining  whether  the  pulsation  continues  when  the  vessel  is 
empty ;  or,  if  practicable,  by  stopping  the  pulsation  in  the  artery 
by  pressure,  and  observing  if  the  venous  pulsation  continues.  The 
movements  due  to  respiration  may  be  arrested  by  causing  the  pa- 
tient to  suspend  breathing  for  a  few  seconds.  Pulsation  is  rarely 
observed  elsewhere  than  in  the  veins  of  the  neck.  It  is  often 
limited  to  the  jugular  veins  just  above  the  clavicles.  It  may  be 
limited  to  one  side  of  the  neck,  and,  when  this  is  the  case,  it  is 
usually  observed  on  the  right  side.  In  some  instances,  however, 
the  pulsation  extends  to  the  superficial  veins  at  remote  parts  of  the 
body.  It  has  been  observed  even  on  the  dorsal  surface  of  the 
hands.^  Pulsation  is  usually  accompanied  by  turgescence  of  the 
veins,  and  is  especially  marked  at  the  end  of  the  act  of  expiration, 
when  the  fulness  is  greatest.  It  may  also  be  increased  by  pressure 
on  the  vein  above  the  point  where  it  is  observed.  It  varies  in 
degree  or  force  between  a  very  gentle  undulatory  and  frequently 
intermittent  movement  perceptible  to  the  eye,  and  a  movement 

'  A  Case  of  Pulsation  in  the  Veins  of  the  Upper  Extremities.  Bj  Charles  Ben- 
son, M.  D.  Dublin  Journal  of  Medical  Science,  vol.  viii.,  series  No.  1,  1S36.  Vide 
Stokes,  op.  cit.,  Am.  ed.,  p.  219. 


VENOUS    PULSATIOX.  1-15 

which  is  not  only  seen,  but  communicates  a  sensation  to  the  finger 
sufi&ciently  distinct  but  never  strong. 

As  a  symptom  of  cardiac  disease,  venous  pulsation  was  first  de- 
scribed by  an  Italian  author,  Lancisi,  who  ascribed  it  to  dilatation 
of  the  right  ventricle.  The  phenomenon,  however,  had  been  pre- 
viously noticed  by  another  Italian  writer.  Testa.'  The  inquiry 
which  first  arises  is,  Does  it  invariably  denote  disease?  Mr.  J.  W. 
King,  in  connection  with  the  subject  of  the  safety-valve  function  of 
the  tricuspid  valve,  adduces  cases  to  show  that  it  occurs  independ- 
ently of  any  organic  disease  of  the  heart.  And  Dr.  Francis  Sibson 
states  that  "a  slight  systolic  pulsation  is  visible,  below  the  sterno- 
cleido,  in  the  superficial  jugular,  in  thirty-nine  persons  out  of  forty, 
when  they  lie  down."^  Assuming  that  a  venous  pulsation  ma}'" 
exist  without  being  abnormal,  the  supposition  Avhich  has  been  en- 
tertained, that  it  may  be  produced  by  the  impulse  communicated 
by  the  contraction  of  the  left  ventricle  being  transmitted  through 
the  capillary  vessels  (t'2s  d  tergo),  is  not  tenable.  It  must  be  due, 
in  health  as  in  disease,  to  a  reflux  current,  and  hence  it  follows, 
assuming  its  occurrence  to  be  synchronous  with  the  ventricular 
systole,  either  that  an  amount  of  tricuspid  regurgitation,  irrespective 
of  disease,  sometimes  occurs  sufficient  to  give  rise  to  a  retrograde 
current  extending  to  the  cervical  veins,  or,  as  contended  by  Hope, 
the  expansion  of  the  curtains  of  the  tricuspid  valve  during  the 
ventricular  systole  suffices  to  impart  to  the  blood  contained  in  the 
right  auricle  a  momentum  which  extends  to  the  column  of  blood 
contained  within  the  veins  for  a  certain  distance.  The  latter  view 
is  not  improbable,  and  both  explanations  are  perhaps  admissible. 
But  it  is  only  when  the  pulsation  is  slight  and  circumscribed  that 
there  is  room  for  doubt  as  to  its  being  a  symptom  of  disease.  If  it 
be  marked  or  extensive,  it  is  to  be  considered,  generally,  as  evi- 
dence of  tricuspid  regurgitation.  Its  significance,  under  these  cir- 
cumstances, renders  it  a  valuable  diagnostic  symptom.  It  is  more 
valuable  in  a  positive  than  in  a  negative  point  of  view :  that  is, 
while  its  presence  in  a  marked  degree  is,  in  general,  evidence  of 
tricuspid  regurgitation,  its  absence  is  not  proof  of  the  non-occur- 
rence of  this  regurgitation.  An  important  element  in  its  production 
is  involved,  in  addition  to  insufficiency  of  the  tricuspid  valve,  viz., 
increased,  or  at  least  undiminished,  muscular  power  of  the  right 


10 


'  Vide  Stokes,  op.  cit.,  Am.  eel.,  p.  214,  note. 

2  Medical  Anatomy.     Londou.     Fasciculus,  No.  1. 


14G      LESIONS    AFFECTING    THE    VALVES    OF    THE    HEART. 

ventricle.  If  tlie  contraction  of  this  ventricle  be  feeble,  from  dilata- 
tion or  wealcness,  the  regurgitant  current  is  not  strong  enough  to 
extend  much,  if  at  all,  beyond  the  auricle  into  the  veins.  On  the 
other  hand,  the  force  of  the  regurgitation  and  the  reflux  into  the 
veins,  other  things  being  equal,  will  be  commensurate  with  the 
power  with  which  the  right  ventricle  contracts.  Hence,  it  is  ob- 
vious that  the  symptom  under  consideration  is  not  only  valuable 
as  evidence  of  tricuspid  regurgitation,  but  also  as  constituting,  in 
some  measure,  an  index  of  the  energy  of  the  systole  of  the  right 
ventricle.  The  conditions  most  favorable  for  the  production  of  the 
venous  pulse  are  free  tricuspid  regurgitation  and  hypertrophy  of 
the  right  ventricle.  These  combined  conditions  are  present  in  con- 
nection not  only  with  valvular  lesions  confined  to  the  right  side  of 
the  heart,  but,  as  has  been  seen,  with  lesions  affecting  the  aortic 
and  mitral  valves  and  orifices,  in  a  certain  proportion  of  cases.  It  is 
easy  to  understand  that  hypertrophy  of  the  right  ventricle,  without 
tricuspid  regurgitation,  may  exaggerate  the  pulsatory  movements 
of  the  cervical  veins  which  are  often  observed  in  a  slight  degree  in 
health.  But  it  is  probably  correct  to  say  that  hypertrophy  of  the 
rioht  ventricle  alone  does  not  give  rise  to  this  symptom  in  a  marked 
decree,  and,  therefore,  that  regurgitation  is  to  be  inferred  in  such 
cases. 

Juo'ular  pulsation  is  to  be  explained  in  the  manner  just  stated 
in  most  of  tlie  instances  in  which  it  is  observed.  In  a  certain  pro- 
portion of  instances,  however,  this  symptom  is  otherwise  produced. 
The  systolic  contraction  of  the  right  auricle  may  cause  a  movement 
of  the  blood  in  a  retrograde  direction  sufficiently  to  give  rise  to 
venous  pulsation.  Experimental  observations  show  that  the  auricu- 
lar systole  precedes,  by  a  very  brief  interval,  the  ventricular,  the 
former  being,  as  it  were,  continued  into  the  latter.  Venous  pulsa- 
tion due  to  auricular  contraction  should  therefore  precede  slightly 
the  arterial  pulse  or  apex-beat  of  the  heart,  while  clinical  observa- 
tion shov/s  that  generally  the  venous  pulse  lags  a  little  behind  that 
of  the  arteries,  the  reflux  venous  current  being  somewhat  slower 
than  the  direct  arterial  current.  The  point  just  stated  suffices  for 
the  discrimination  between  an  auricular  and  ventricular  venous 
pulse,  and  it  is  perhaps  true  that  adequate  attention  has  not  been 
o-iven  to  this  discrimination  in  observations  of  disease.  But  it  is 
probably  correct  to  consider  venous  pulsation  as  referable,  in  the 
vast  majority  of  cases,  to  the  action  of  the  right  ventricle.  In  a 
case  recently  under  observation,  a  double  undulation  of  the  super- 


SYMPTOMS  REFERABLE  TO  CIRCULATIOX.      1-iT 

ficial  jugular  vein  on  the  right  side  of  the  neck  existed,  one  pre- 
ceding and  the  other  coinciding  with  the  ventricular  systole.'  The 
veins  of  the  neck  were  extremely  turgid ;  and  examination  after 
death  disclosed  lesions  of  the  tricuspid  orifice  involving  considerable 
obstruction  as  well  as  regurgitation,  together  with  great  dilatation 
of  the  right  auricle,  and  enlargement,  by  hypertrophj^,  of  the  right 
ventricle. 


Symptoms  and  Pathological  Effects  referable  to  the  Circulatiox. 

The  symptoms  just  considered,  viz.,  the  abnormal  variations  of 
the  pulse,  turgescence  of  the  veins,  and  venous  pulsation,  relate  to 
the  circulation,  but  they  are  due  immediately  to  the  heart,  and 
hence  represent  directly  its  morbid  conditions.  Other  results  of 
disease  relate  to  the  circulation,  but  are  developed  as  ulterior 
effects  of  valvular  affections,  involving  intermediate  conditions, 
and,  therefore,  representing  indirectly  those  which  are  seated  in  the 
heart.  Under  the  present  head  are  embraced  two  important  events 
incidental  to  the  clinical  history  of  affections  of  the  valves  and 
orifices,  to  wit,  dropsy  and  arterial  obstruction  from  masses  of  solid 
deposit  detached  from  the  endocardial  membrane,  and  carried  with 
the  current  of  blood  into  the  vessels.  Important  pathological 
events  in  addition  to  these  relate  to  the  circulation,  but  will  be 
more  appropriately  considered  in  connection  with  the  phenomena 
referable  to  different  organs.  Such  are  hemorrhage,  apoplectic 
extravasation,  flux,  etc. 

Cardiac  Dropsy. — Serous  transudation  into  the  areolar  tissue 
beneath  the  integument,  into  the  pulmonary  parenchyma,  the  peri- 
toneal and  other  serous  cavities,  in  other  words,  general  dropsy, 
occurs  sooner  or  later  in  a  large  proportion  of  the  cases  of  valvular 
affections  in  which  a  fatal  termination  does  not  take  place  in  conse- 
quence of  some  intercurrent  or  incidental  disease.     General  dropsy 

'  Hospital  Records,  New  Orleans  Charity  Hospital,  vol.  xiv.  p.  271.  The  relation 
of  pulsation  of  the  cervical  veins  to  the  contractions  of  the  right  auricle  is  an  in- 
teresting subject  for  further  clinical  study  than  appears  to  have  been  as  yet  given 
to  it.  Prof.  Skoda  attributes  this  symptom,  in  certain  cases,  to  the  auricular  sys- 
tole. Vide  On  the  Functions  of  the  Auricles  of  the  Heart,  translated  from  Schmidt's 
Jahrhucher,  July,  1853,  by  W.  0.  Markham,  M.  D.,  Brif.  and  For.  3fed.-Chir.  Rev., 
Feb.  1854. 


l-i'S      LESIONS    AFFECTING   THE    VALVES    OF    THE    HEART. 

dependent  on  disease  of  the  heart  is  called  cardiac  dropsy.  It  may 
be  due  to  other  pathological  conditions,  generally  to  disease  of  the 
kidney,  when  it  is  distinguished  as  renal  dropsy.  It  appears  first, 
as  a  rule,  in  the  form  of  cedema  of  the  feet  and  ankles,  which 
gradually  extends  over  the  lower  extremities.  CEdema  of  the  face 
follows,  sometimes  occurring  nearly  simultaneously  with,  and  occa- 
sionally prior  to,  swelling  of  the  feet.  It  may  extend  over  the 
whole  bod}'-,  constituting  anasarca.  The  lower  extremities,  in  some 
cases,  become  enormously  swollen.  Erythema,  and  occasionally 
gangrene,  result  from  the  extreme  distension  of  the  integument. 
Blisters,  ulcerations,  and  cracks  are  other  consequences,  giving  exit 
to  the  transuded  liquid,  which  flows  away  in  abundance.  The  sur- 
face, more  especially  the  face,  presenting  at  the  same  time  more  or 
less  venous  congestion,  the  general  aspect  in  cardiac  dropsy  is 
somewhat  characteristic.  The  face  has  a  dark  or  dusky  hue,  form- 
ing a  striking  contrast  to  the  pallid  complexion  which  is  usually 
marked  in  cases  of  dropsy  from  renal  disease,  or  when  it  occurs  iu 
connection  with  ansemia  from  whatever  cause  induced.  Efi'usiou 
into  the  different  serous  cavities  takes  place  subsequently  to  the 
subcutaneous  oedema.  Dr.  AYalshe  ranks  oedema  of  the  pulmonary 
parenchyma  over  dropsy  of  the  cavities,  as  respects  frequency  of 
occurrence.  Mention  will  be  made  of  this  under  the  head  of  patho- 
logical events  referable  to  the  pulmonary  system.  The  different 
serous  cavities  are  by  no  means  equally  liable  to  dropsical  effusion. 
The  following  is  an  enumeration  of  the  several  cavities  after  the 
relative  frequency  with  which  they  are  found  to  be  affected  in 
diseases  of  the  heart:  Peritoneal,  pleural,  pericardial,  arachnoid, 
subarachnoid,  and  the  tunica  vaginalis.'  More  or  less  of  these,  and 
sometimes  all  of  them,  present  dropsical  accumulation  in  the  same 
case. 

The  occurrence  of  dropsy  has  reference  to  the  situation,  nature, 
and  degree  of  valvular  lesions.  Tricuspid  contraction  is  the  lesion 
which  most  directly  and  efficiently  tends  to  give  rise  to  this  effect ; 
but  this  lesion  is  exceedingly  infrequent.  Tricuspid  regurgitation 
exerts  a  similar  tendency,  but  in  a  less  degree.  Dropsy  does  not 
uniformly  occur  in  the  cases  in  which  turgescence  of  the  veins  and 
venous  pulsation  show  marked  insufficiency  of  the  tricuspid  valve. 
Of  lesions  situated  in  the  left  side  of  the  heart,  mitral  contraction  is 
most   likely  to  give  rise  to  dropsy.     Mitral  regurgitant   lesions 

'  Walshe,  Diseases  of  the  Lungs  aud  Heart,  English  edition,  p.  64S. 


CARDIAC    DROPSY.  149 

come  next  in  order,  as  regards  this  tendency.  Aortic  lesions, 
oftener  than  mitral,  continue  and  terminate  without  this  patho- 
logical effect ;  but  they  are  by  no  means  always  exempt  from  it. 
By  what  mechanism  is  the  dropsy  produced?  So  far  as  concerns 
the  agency  of  the  cardiac  lesions,  the  intermediate  morbid  condition 
is  passive  congestion  of  the  systemic  veins.  To  understand  the 
modus  operandi^  we  have  to  inquire  in  what  manner  the  different 
obstructive  and  regurgitant  lesions  induce  this  venous  congestion. 
This  is  sufficiently  intelligible  as  regards  lesions  seated  at  the 
tricuspid  orifice.  The  relations  of  the  systemic  veins  to  the  right 
side  of  the  heart  are  such  that  this  consequence  of  obstruction  and 
regurgitation  situated  here  is  at  once  evident.  It  is  not  less  clear 
when  the  lesions  are  situated  at  the  mitral  and  aortic  orifices,  in 
view  of  the  efibcts  of  these  on  the  right  side  of  the  heart,  which 
have  been  already  considered.  Dropsy  follows  the  latter  lesions  in 
consequence  of  the  distension  and  dilatation  of  the  right  ventricle 
and  auricle  to  which  these  lesions  give  rise.  Repletion  of  these 
cavities  constitutes  an  obstruction  which  may  induce  sufficient  con- 
gestion of  the  systemic  veins  to  lead  to  serous  transudation.  Thus, 
so  far  as  concerns  the  relation  of  dropsy  to  valvular  lesions,  they 
all  alike  produce  this  effect  by  obstruction  at  the  termination  of 
the  systemic  venous  system,  viz.,  the  right  auricle ;  tricuspid  lesions, 
involving  directly  this  obstruction,  and  lesions  situated  at  the  mitral 
or  aortic  orifice,  leading  indirectly  to  the  same  result.  Dr.  Blakis- 
ton  supposes  insufficiency  of  the  tricuspid  valve  to  exist  whenever 
dropsy  proceeds  from  lesions  situated  in  the  left  side  of  the  heart. 
It  has  been  seen  that  the  enlargement  of  the  right  ventricle,  con- 
sequent more  especially  on  mitral  lesions,  not  unfrequently  induces 
an  augmentation  of  the  tricuspid  orifice,  rendering  the  valve  insuffi- 
cient. The  regurgitation  which  takes  place  in  these  cases  doubt- 
less adds  considerably  to  the  congestion  of  the  systemic  veins.  Dr. 
Blakiston  presents  a  collection  of  cases  illustrative  of  this  fact.' 
But  clinical  observation  shows  that  dropsy  may  occur  in  connection 
with  lesions  situated  in  the  left  side  of  the  heart  without  the  inter- 
vention of  either  tricuspid  contraction  or  abnormal  insufficiency. 

From  the  foresjoinoj  remarks  it  follows  that  the  occurrence  of 
dropsy,  other  things  being  equal,  in  cases  of  mitral  or  aortic  lesions, 
will  depend,  not  immediately  on  the  nature  and  extent  of  these 

'  Practical  Observations  on  Certain  Diseases  of  the  Chest,  and  on  the  Principles 
of  Auscultation,  Am.  ed.,  1848,  p.  231  et  seq. 


150      LESIONS    AFFECTIXG    THE    VALVES    OF    THE    HEART. 

lesions,  but  on  conditions  induced  thereby,  whicb  relate  to  the 
right  side  of  the  heart.  When  to  distension  of  the  right  ventricle 
and  auricle  is  added  either  dilatation  or  weakness  of  the  right 
ventricle,  the  venous  obstruction  due  to  over-accumulation  of  blood 
is  increased  by  the  diminished  ability  of  this  ventricle  to  contract 
and  expel  its  contents.  In  point  of  fact,  dilatation  of  the  right 
ventricle  or  weakness  from  fatty  degeneration,  or  other  causes, 
precedes,  in  the  great  majority  of  cases,  the  occurrence  of  dropsy. 
Dropsy,  therefore,  is  an  event  which  usually  belongs  to  an  advanced 
period  of  organic  disease,  and  it  is  frequently  a  precursor  of  a  fatal 
termination.  Enlargement  of  the  right  side  of  the  heart,  especially 
if  accompanied  by  degeneration  of  structure  or  great  muscular 
weakness,  may  induce  dropsy  when  valvular  lesions  are  not  present. 
The  occurrence  of  dropsy,  thus,  when  aortic  or  mitral  lesions  are 
present,  is  evidence  that  the  effects  of  these  lesions  on  the  right  side 
of  the  heart,  which  have  been  considered  under  another  head,  have 
taken  place. 

The  mechanism  of  dropsy  occurring  in  connection  with  valvular 
affections,  so  far  as  at  present  considered,  involves  simply  mechani- 
cal pressure.  The  serous  or  watery  portion  of  the  blood  transudes 
through  the  coats  of  the  vessels  in  consequence  of  their  distension, 
in  the  same  manner  that  oedema  of  an  extremity  is  induced  by  the 
obliteration  of  an  important  venous  trunk  coming  from  it.  Abnor- 
mal conditions  in  addition  to  those  giving  rise  to  venous  obstruc- 
tion, however,  may  concur  in  producing  cardiac  dropsy.  The 
frequent  concurrence  of  other  causes  is  shown  by  the  absence  of 
dropsy  in  cases  in  which  the  conditions  pertaining  to  the  heai-t 
must  necessarily  have  involved,  for  a  long  period,  marked  con- 
gestion of  the  systemic  veins.  Aortic  and  even  mitral  lesions, 
involving  a  great  degree  of  regurgitation  and  contraction,  may  end 
after  a  protracted  duration  without  having  led  to  dropsy.  It  is 
shown  also  by  the  want  of  proportion,  which  all  clinical  observers 
have  noticed,  between  the  occurrence  or  the  amount  of  dropsical 
transudation  and  the  degree  of  obstruction  which  the  cardiac  con- 
ditions involve.  Not  only  are  these  conditions'marked  in  cases  in 
Avhich  dropsy  has  not  occurred,  but  dropsy  occurs  in  other  cases  in 
which  these  conditions  are  comparativel3'  slight.  Evidently,  then, 
something  more  than  mechanical  pressure  is  concerned  in  the  pro- 
duction of  dropsy  in  at  least  a  certain  proportion  of  the  cases  of 
cardiac  disease  in  which  this  pathological  effect  takes  place.  Clinical 
experience  shows  that  in  some  instances  a  concurring  morbid  con- 


EMBOLI.E.  151 

dition  is  disease  of  kidney.  Disease  of  heart  and  tlie  affection  of 
kidne}^  commonly  known  as  Bright's  disease,  are  occasionally  found 
associated.  The  causes  which  induce  dropsy  in  the  latter  affection, 
then  co-operate  with  those  relating  to  the  heart.  Renal  and  cardiac 
dropsy  are,  in  fact,  combined.  Anaemia  or  hydr^emia,  arising  from 
various  causes,  may  determine  the  occurrence  of  dropsy,  when  the 
cardiac  lesions  of  themselves  would  not  have  produced  it.  Transu- 
dation of  the  attenuated  serum,  it  is  well  known,  takes  place  as  a 
result  of  this  condition  of  the  blood  when  neither  cardiac  nor  renal 
disease  exists.  Dr.  Walshe  attaches  importance  to  the  impaired 
nutrition  of  the  walls  of  the  vessels  from  the  strain  incident  to  pro- 
longed distension,  as  a  subsidiary  cause  of  transudation.  These 
additional  conditions  are  to  be  taken  into  account  in  explaining 
the  production  of  dropsy  in  cases  of  cardiac  disease ;  and  they 
serve  to  explain  the  efficiency  of  therapeutical  measures  in  some 
instances  in  which  the  cardiac  lesions  are  such  as  to  render  the 
continuance  of  venous  congestion  inevitable. 

Arterial  obstruction  hy  fibrinous  deposits  detached  from  tlie  valves  or 
orifices  of  the  heart.  EmboJia: — This  subject  has  only  within  the  past 
few  years  engaged  the  attention  of  pathologists  and  clinical  observers. 
A  sufficient  number  of  facts  have  been  ascertained,  to  show  that  it 
is  entitled  to  be  considered  among  the  interesting  and  important 
effects  of  valvular  affections.  Further  investigation,  however,  is 
required,  in  order  to  determine  fully  how  far  it  is  involved  in  the 
pathological  history  of  these  affections.  As  already  remarked,  in 
describing  the  morbid  appearances  which  are  presented  in  cases  of 
lesions  of  the  valves  and  orifices,  the  deposits  distinguished  as 
vegetations,  warty  excrescences,  etc.,  are  frequently,  in  examina- 
tions after  death,  found  to  be  so  slightly  adherent  that  it  is  reason- 
able to  suppose  the  current  of  blood  to  be  sufficient,  in  some  in- 
stances, to  detach  them  during  life.  They  are  then  carried  onward 
with  the  current  in  the  course  of  the  circulation,  until  they  reach 
an  arterial  trunk  smaller  than  their  own  dimensions.  Here  they 
are  arrested,  and,  becoming  wedged  in  the  vessel,  they  act  as  plugs, 
obstructing  the  passage  of  blood  in  the  artery  and  its  branches  be- 
yond the  point  at  which  they  are  lodged.  These  detached  deposits 
are  called  emboli^  or  migratory  plugs,  by  Prof.  E.  Yirchow,  of 
Wiirzburg,  who  appears  to  have  been  the  first  to  make  obstruction 
of  the  systemic  arteries,  as  thus  produced,  a  subject  of  scientific 


152      LESIONS    AFFECTING   THE    VALVES    OF    THE    HEART. 

study.'  Others  have  contributed  the  results  of  their  researches, 
among  whom  Dr.  AVilliam  Senhouse  Kirkes,  of  Loudon,  is  to  be 
especially  mentioned.^  The  subject  is  designated  by  the  term 
embolia.  This  term,  however,  embraces  migratory  plugs  formed 
elsewhere  than  in  the  heart.  They  may  be  formed  in  the  arteries 
and  in  the  veins,  in  the  latter  case  being  sometimes  transported  to 
the  heart,  and  thence  into  the  branches  of  the  pulmonary  artery. 
Those  which  consist  of  vegetations  or  warty  excrescences  detached 
from  the  valves,  do  not  embrace  all  which  may  be  derived  from 
the  heart.  Eecently  deposited  fibrin  and  coagulable  lymph  occur- 
ring during  the  progress  of  endo-carditis,  and  fibrinous  clots  formed 
under  various  pathological  circumstances,  also  constitute  emboli. 
The  subject,  therefore,  is  not  limited  to  valvular  lesions  in  its  ap- 
plication, and  will  be  referred  to  hereafter,  in  treating  of  endo-car- 
ditis and  the  formation  of  coagula  within  the  heart. 

Detached  deposits  from  within  the  heart,  in  cases  of  chronic  val- 
vular lesions,  are  derived,  in  the  vast  majority  of  cases,  from  the 
left  ventricle,  since  lesions  affecting  the  valves  of  the  right  side 
of  the  heart  are  exceedingly  infrequent.  The  obstructed  arteries, 
therefore,  belong  to  the  systemic  class,  the  emboli  passing  with 
the  current  of  blood  into  the  aorta  and  along  the  successive  arterial 
trunks,  until  arrested  in  their  progress  by  branches,  the  calibre  of 
which  is  too  small  to  permit  their  farther  progress.  The  situation 
in  which  an  embolus  becomes  fixed,  will  depend  on  its  size  and 
the  direction  which  it  happens  to  take.  Owing  to  the  large  quantity 
of  blood  sent  to  the  brain,  it  will  be  likely  to  take  that  direc- 
tion, and  produce  obstruction  of  some  one  of  the  cerebral  arteries. 
Cases  reported  by  Dr.  Kirkes,  and  otheis,  seem  to  show  that  in 
this  manner,  circumscribed  softening  of  the  brain  originates;  and 
that  the  occurrence  of  paralysis  in  connection  with  valvular  lesions 
of  the  heart,  may  be  thus  accounted  for  in  a  certain  proportion  of 

'  Vide  Brit,  and  For.  Med.-Cliir.  Rev.,  July,  1S57,  p.  15.  Vircliow's  earliest 
researches  were  in  1845.  His  later  piiblications  on  this  subject  are  contained  in 
Gesammelte  Abhandhingen  zur  Wissenschaftlichen  Medicin,  Frankfurt  am  Main,  1856, 
and  Ilandbuch  der  Speciallen  Pathologie  und  Therapie,  vol.  i.,  1854.  The  reader 
will  find  a  review  of  the  first  of  these  works  in  the  No.  of  the  Brit,  and  For.  Med.- 
Chir.  Rev.  just  referred  to,  and  an  able  analytical  review  of  the  last  in  the  North 
American  Med.-Chir.  Rev.,  No.  for  July,  1858. 

^  "  On  some  of  the  Principal  Effects  resulting  from  the  Detachment  of  Fibrinous 
Deposits  from  the  Interior  of  the  Heart  and  their  mixture  with  the  Circulating 
Blood,"  by  William  Senhouse  Kirkes,  M.  D.,  Trans.  Med.-Chir.  Society  of  London, 
1852. 


EMBOLIC.  153 

cases.  Or,  the  embolus  may  follow  the  current  downwards  through 
the  descending  aorta,  and  become  lodged  in  some  one  of  the  second- 
ary branches.  It  seems  to  be  sufficiently  established  that  obstruc- 
tion of  the  renal,  splenic,  iliac,  femoral,  and  other  arteries  may  be 
thus  produced.  Numbness,  impaired  muscular  power  of  the  lower 
extremities,  loss  of  pulsation  in  the  arteries  accessible  to  the  touch, 
and  even  gangrene,  have  been  observed  as  probable  results  of  ob- 
struction of  the  iliac  and  femoral  arteries.' 

The  production  of  arterial  obstruction  by  detached  deposits  is 
rendered  highly  probable  by  the  facts  already  stated,  viz.,  the  fre- 
quency with  which  loosely  attached  masses  of  variable  size  are 
observed  on  the  valves  in  post-mortem  examinations,  and  the 
occurrence  of  paralysis  and  other  effects,  in  cases  of  valvular  dis- 
ease, which  may  fairly  be  attributed  to  this  cause.  But  the  proof 
rests  mainly  on  the  identity  of  the  emboli  or  plugs  found  in  the 
arteries  with  the  deposits  existing  at  the  same  time  on  the  valves. 
To  this  point  the  attention  of  pathologists  has  been  directed,  and 
in  numerous  cases  which  have  been  reported  this  identity  appears 
to  have  been  sufficiently  established.  The  fact  of  obstruction  being 
ascertained,  together  with  the  existence  of  local  changes  (in  the 
brain  especially),  which  are  apparently  due  to  this  obstruction, 
the  obstructing  mass  has  been  found  not  only  to  resemble  in  its 
gross  appearances  the  vegetations  or  warty  excrescences  coexisting 
within  the  heart,  but  to  possess  the  same  composition  and  formation 
as  determined  by  microscopical  examination.  The  plugs  are  some- 
times calcareous,  coexisting  deposits  within  the  heart  having  under- 
gone a  similar  transformation. 

Other  eflects  attributed  to  the  removal  of  deposits  on  the  valves 
or  orifices,  and  their  transportation  with  the  current  of  blood  into 
the  arteries,  may  be  here  alluded  to.  Instead  of  being  detached  in 
masses  of  greater  or  less  size,  they  may  be  disintegrated  and 
carried  away  in  small  particles.  It  is  easy  to  conceive  of  a  con- 
siderable quantity  of  the  debris  of  fibrinous  and  calcareous  deposits 
in  this  way  accumulating  within  the  vessels.     This  does  not  occa- 

'  Since  this  chapter  was  written,  I  have  met  with  an  instance  of  the  formation 
of  large  masses  of  calcareous  matter  within  the  right  ventricle,  and  the  impaction 
of  a  mass  as  large  as  a  pullet's  egg  in  the  left  pulmonary  artery.  This  division  of 
the  pulmonary  artery  was  completely  obstructed  by  the  calcareous  mass  which 
had  evidently  been  detached  from  within  the  ventricle,  the  fractured  surface 
being  apparent.  Pulmonary  tuberculosis  coexisted  in  this  case,  the  tuberculous 
deposit  being  most  abundant  in  the  right  side. 


15-i   LESIOXS  AFFECTING  THE  VALVES  OF  THE  HEART. 

sion  palpable  obstructioa  of  arterial  trunks  like  the  plugs  or 
emboli,  but  accumulating  in  the  minute  or  capillary  vessels  in 
certain  organs,  local  congestions  and  impaired  nutrition  may  arise 
therefrom.  Other  and  more  serious  consequences  are  imputed  to 
the  admixture  of  these  particles  with  the  blood.  It  is  supposed 
that  phenomena  indicative  of  a  morbid  poison  in  the  blood  may  be 
thereby  induced.  Cases  in  which  typhoid  symptoms,  petechial 
eruptions,  etc.,  occur  in  the  course  of  heart  affections  are  thus 
explained.  This  pathological  view  is,  and  must  of  necessity  con- 
tinue to  be,  hypothetical,  since  it  is  difficult,  if  not  impossible,  to 
demonstrate  the  presence  of  these  particles,  and  their  derivation 
from  the  heart.  The  doctrine  has  reference  more  to  the  recent 
products  of  inflammation  deposited  on  the  valves  than  to  the 
deposits  of  long  standing  which  characterize  chronic  valvular 
lesions.  These  deposits,  from  their  consistency,  are  more^  likely  to 
be  detached  in  masses  than  to  be  disintegrated  and  carried  away 
in  fine  particles,  while  soft  lymph  or  fibrin  is  readily  removed  in 
the  latter  mode.  Moreover,  clinical  observation  shows  that  symp- 
toms denoting  blood  poisoning  very  rarely  occur  during  the  pro- 
gress of  chronic  valvular  lesions. 


Symptoms  and  Pathological  Effects  eeferable  to  the  Respiratory 

System. 

The  phenomena  referable  to  the  lungs,  in  connection  with  val- 
vular lesions,  irrespective  of  associated  or  intercurrent  pulmonary 
affections,  depend,  for  the  most  part,  on  vascular  engorgement  of 
these  organs.  Congestion  of  the  lungs  is  an  immediate  result  of 
an  impediment  to  the  free  admission  of  blood  into  the  left  auricle 
from  the  pulmonary  veins.  An  impediment  exists  whenever  the 
left  auricle  is  over-distended  with  blood ;  and  over-distension  of 
this  auricle  occurs  as  a  consequence  of  any  interruption  of  the 
blood-currents  through  the  orifices  of  the  left  side  of  the  heart. 
These  effects  are  involved  more  directly  and  in  a  greater  degree  in 
mitral  than  in  aortic  lesions.  Obstructive  lesions  at  the  mitral 
orifice  especially  give  rise  to  pulmonary  congestion.  The  pheno- 
mena dependent  thereon  are  most  marked,  other  things  being 
equal,  in  cases  characterized  by  extreme  contraction  of  this  orifice. 
Mitral  regurgitation  leads  to  pulmonary  congestion  and  its  depend- 
ent phenomena,  but  not  so  readily  nor  to  the  same  extent  as  in 


CONGESTION    OF    THE    LUNGS,  155 

cases  of  obstruction.  The  effects  of  regurgitation,  however,  are 
often  added  to  those  of  contraction.  Aortic  lesions,  obstructive 
and  regurgitant,  also,  sooner  or  later,  are  followed  by  over-disten- 
sion and  dilatation  of  the  left  auricle  and  consequent  congestion  of 
the  lungs.  Dilatation  of  the  left  ventricle,  however,  precedes  these 
effects,  and  the  latter  are  produced  more  tardil}^  than  when  the 
lesions  are  situated  at  the  mitral  orifice.  In  the  rare  instances  of 
lesions  occasioning  obstruction  or  regurgitation  at  the  tricuspid 
and  pulmonic  orifices,  the  over-distension  of  the  right  auricle 
which  ensues  constitutes  an  impediment  to  the  circulation  which 
affects  the  systemic  vessels,  not  extending  to  the  pulmonary  vascu- 
lar system  unless  the  left  ventricle  becomes  dilated.  Engorgement 
of  the  lungs,  therefore,  is  a  special  pathological  effect  of  lesions 
affecting  the  orifices  at  the  left  side  of  the  heart,  as  congestion  of 
the  systemic  veins  is,  in  like  manner,  a  special  pathological  effect 
of  an  impediment  existing  in  the  right  side.  This  statement 
.applies  to  valvular  lesions.  It  does  not  apply  to  another  morbid 
condition  which  may  contribute  to  pulmonary  congestion,  viz., 
dilatation  or  weakness  of  the  right  ventricle.  The  blood  accumu- 
lates in  the  vessels  of  the  lungs  in  consequence  of  not  being  pro- 
pelled by  this  ventricle  with  sufficient  power.  Yenous  congestion 
is  due  to  deficiency  in  the  vis  a  tergo.  Dilatation  of  the  right 
ventricle,  which  is  an  effect  of  the  engorgement  of  tlie  lungs 
incident  to  mitral  or  aortic  lesions,  thus  tends  to  augment  the 
difficulty  of  the  circulation  through  the  pulmonary  circuit.  An 
enfeebled  condition  of  the  right  ventricle  is,  in  itself,  adequate  to 
produce  pulmonary  congestion,  as  is  seen  in  some  cases  of  fatty 
degeneration  affecting  this  ventricle,  but  not  to  the  extent  of  val- 
vular lesions  involving  interruption  of  the  blood-currents  tlirough 
the  orifices  in  the  left  side  of  the  heart.  These  remarks  are  alike 
applicable,  mutatis  mutandis^  to  dilatation  or  weakness  of  the  left 
ventricle  in  connection  with  congestion  of  the  systemic  veins. 

The  engorgement  of  the  lungs  arising  from  valvular  lesions  gives 
rise  to  important  pulmonary  symptoms  without  any  other  superin- 
duced affection  of  these  organs.  The  most  prominent  of  these 
symptoms  are,  dyspnoea,  cough,  muco-serous  expectoration,  and 
hiemoptysis.  Certain  pulmonary  affections  appear  in  some  instances 
to  be  dependent  directly  and  exclusively  on  over-distension  of  the 
vessels,  viz.,  extravasation  of  blood,  or  apoplexy  of  the  luugs,  and 
oedema.  Other  affections  are  incidental  to  valvular  lesions,  the 
state  of  congestion  predisposing  to  them,  or  favoring  their  devel- 


15()   LESIOXS  AFFECTIXG  THE  TALYES  OF  THE  HEART. 

opment.  The  existence  of  valvular  lesions,  thus,  involves  a  liability 
to  bronchitis,  pneumonitis,  pleurisy  and  emphysema. 

Dyspnoea  is  a  symptom  more  or  less  prominent  in  the  great 
majority  of  cases.  If  there  be  no  superinduced  or  incidental  affec- 
tion of  the  lungs,  the  difficulty  of  breathing  is  proportionate  to  the 
amount  of  pulmonary  congestion.  It  is  a  criterion  of  the  extent 
to  which  the  changes  effected  by  respiration  are  compromised  in 
consequence  of  the  retarded  flow  of  blood  through  the  capillary 
vessels.  It  occurs  earlier  and  is  more  marked  in  cases  of  mitral 
than  aortic  lesions,  because  the  former  tend  more  directly  and  in  a 
greater  degree  to  engorgement  of  the  pulmonary  vessels.  In  most 
cases  of  either  mitral  obstruction  or  regurgitation,  dyspnoea  is  the 
first  symptom  which  occasions  inconvenience.  The  patient  often 
complains  of  this  sj^mptora  alone,  or  chiefly,  for  a  considerable 
period.  In  cases  of  aortic  lesions  it  occurs  later  and*  is  oftener 
preceded  by  palpitation  or  other  sjnTiptoms  referred  by  the  patient 
to  the  heart.  It  is  not  uncommon  to  meet  with  examples  of  great 
contraction  and  insufficiency  at  the  aortic  orifice,  accompanied  by 
considerable  enlargement  of  the  left  ventricle,  when  there  had  been 
little  or  no  embarrassment  of  respiration.  Instances  are  much  less 
frequent  of  a  similar  amount  of  obstruction  or  regurgitation  at  the 
mitral  orifice,  which  had  not  given  rise  to  dyspnoea.  When  de- 
pendent on  aortic  lesions,  this  symptom  is  evidence  of  enlargement 
of  the  heart,  since  pulmonary  engorgement  does  not  occur  until  the 
left  ventricle  becomes  dilated.  When  dependent  on  mitral  lesions, 
dyspnoea  may  be  experienced  prior  to  much  enlargement,  the  right 
ventricle  becoming  dilated  or  hj-pertrophied  as  an  immediate  result 
of  the  retarded  circulation  throuoh  the  luu2;s.  To  the  condition 
which  the  symptom  represents,  viz.,  pulmonary  congestion,  enlarge- 
ment of  the  heart  is  thus  antecedent  in  cases  of  aortic,  and  con- 
secutive in  cases  of  mitral  lesions. 

The  intensity  of  dyspnoea  varies  greatly  in  the  different  cases  of 
valvular  affections  in  which  this  symptom  is  present,  and  in  the 
same  case  at  different  periods.  It  consists,  at  first,  of  a  slight  defi- 
ciency of  breath  on  exertion.  This  progressively  increases  until 
active  exercise  becomes  insupportable.  If  the  patient  pursue  an 
occupation  which  requires  strong  muscular  movements,  he  finds  it 
difficult,  after  a  time,  to  continue  them,  and  is  at  length  compelled 
to  give  up  labor.  Cases  frequently  at  this  juncture  first  come  under 
medical  observation.  The  breathing  may  be  sufficiently  easy  so 
long  as  quietude  of  the  body  is  maintained,  when  the  dyspnoea  is 


DYSPXCEA.  157 

marked  on  taking  moderate  exercise,  even  walking  across  the  room. 
Ha.bitual  dj^spncea,  in  some  instances,  does  not  occur,  or  it  takes 
place  only  during  the  latter  part  of  life.  Other  cases  are  charac- 
terized by  paroxysms  of  difficult  breathing  when  not  provoked  by 
exercise,  and  more  or  less  difficulty  may  be  apparent  constantly. 
There  is  a  notable  difference  in  different  cases  as  regards  the  con- 
sciousness of  dyspnoea  and  the  amount  of  suffering  occasioned  b}'- 
the  same  apparent  difficulty.  The  breathing  is  sometimes  evidently 
labored  when  the  patient  makes  no  complaint,  and  says  he  expe- 
riences no  inconvenience.  This  is  probably  owing,  in  part,  to  the 
symptom  having  been  so  gradually  and  imperceptibly  developed 
that  the  mind  becomes  accustomed  to  it,  and  it  is  scarcely  noticed 
so  long  as  the  habitual  amount  of  difficulty  only  exists.  The  dis- 
tress is  not  commensurate  with  the  manifestations  of  difficulty,  in 
other  instances,  because  the  perceptions  are  blunted  by  the  circula- 
tion of  imperfectly  oxygenated  blood.  In  these  instances  more  or 
less  lividity  of  the  prolabia  and  surface  of  the  body  is  apparent. 
The  suffering,  however,  is  often  great.  The  want  of  more  breath 
is  painfully  felt,  amounting  sometimes  to  a  sense  of  suffocation. 
The  patient  cannot  lie  down,  but  is  obliged  to  keep  the  sitting  pos- 
ture, often  bending  forward  and  supporting  himself  by  the  hands 
locked  below  the  knees,  or  resting  upon  some  solid  body.  The 
accessory  muscles  are  brought  into  play,  to  produce  the  greatest 
possible  expansion  of  the  chest.  The  countenance  expresses  great 
anxiety,  and  frequently  the  lips  and  face  are  livid.  Dyspnoea 
having  this  intensity  is  distinguished  as  orthopnoea.  Occurring  in 
paroxysms,  it  constitutes  the  cardiac  asthma  of  writers. 

These  diversities  as  regards  dyspnoea  show  that  this  symptom  is 
affected  by  a  variety  of  circumstances.  As  an  objective  symptom, 
its  intensity  corresponds  to  the  amount  of  pulmonary  congestion, 
provided  no  other  affection  of  the  lungs  be  present.  Subjectively, 
its  intensity  depends,  in  a  great  measure,  on  tlie  rapidity  or  slowness 
with  which  the  pulmonary  congestion  has  ensued :  that  is,  the  suffer- 
ing incident  to  dyspnoea,  when  it  is  rapidly  developed,  is  far  greater 
than  when  it  has  been  gradually  induced.  The  striking  difference 
among  different  persons  in  susceptibility  to  painful  impressions 
serves  also  to  explain  the  greater  tolerance  by  some  patients  than 
by  others  of  apparently  an  equal  amount  of  difficulty  of  breathing. 
Affections  of  the  pulmonary  organs,  superadded  to  congestion, 
contribute  to  increase  the  amount  of  dyspnoea.  Emphysema,  in 
connection  with  valvular  lesions,  in  proportion  to  its  extent,  adds 


158      LESIOXS    AFFECTING    THE    VALYES    OF    THE    HEART. 

intensity  to  this  symptom.  This  combination  is  not  infrequent,  and 
the  cardiac  affection  is  liable  to  be  overlooked  unless  due  attention 
be  directed  to  an  examination  of  the  heart.  Pleuritic  effusion 
increases  the  dyspnoea  by  diminishing  the  volume  of  lung  and 
limiting  the  range  of  thoracic  expansion.  Bronchitis  produces 
the  same  effect,  the  supply  of  air  to  the  cells  being  diminished  by 
swelling  of  the  bronchial  mucous  membrane  and  the  accumulation 
of  mucus  within  the  tubes,  ffidema  compromises  the  breathing 
capacity  of  the  lungs  in  proportion  as  the  air-cells  become  filled 
with  effused  liquid.  The  coexistence  of  these  or  other  pulmonary 
affections  of  course  invalidates,  to  a  greater  or  less  extent,  the  sig- 
nificance of  dyspnoea  as  representing  the  amount  of  pulmonary 
congestion  due  to  valvular  lesions.  It  is  only  when  pulmonary  com- 
plications are  excluded  that  this  symptom  is  to  be  considered  as  a 
criterion  of  the  impediment  to  the  pulmonary  circulation  which 
these  lesions  occasion.  Spasm  of  the  muscular  fibres  of  the  bron- 
chial mucous  membrane — in  other  words,  true  asthma — may  occur 
in  connection  with  valvular  lesions.  This  explains,  in  some  in- 
stances, the  occurrence  of  the  paroxysms  of  dj'spnoea  or  orthopnoea 
which  constitute  cardiac  asthma.  Various  circumstances,  however, 
which  occasion,  temporarily,  a  considerable  increase  of  the  pulmo- 
nary congestion,  may  give  rise  to  these  paroxysms.  The  disturbed 
action  of  the  heart  which  generally  exists  during  attacks  of  angina 
pectoris,  renders  dyspnoea,  in  some  cases,  an  important  element  in 
that  superadded  affection. 

Cough  and  expectoration  are  usually  present  when  valvular 
lesions  have  induced  considerable  pulmonary  engorgement.  The 
congested  state  of  the  bronchial  mucous  membrane  leads  to  an 
abnormal  secretion  of  mucus,  and  transudation  through  the  coats 
of  the  vessels  into  the  tubes.  The  expectoration  is  muco-serous  in 
its  character.  Varying  in  amount  in  different  cases,  i;  may  be 
considerable  without  involving  inflammation  of  the  membrane. 
The  affection,  under  these  circumstances,  is  bronchorrhoea.  But 
bronchitis  is  apt  to  become  developed,  giving  rise  to  more  cough, 
with  an  expectoration  of  modified  mucus  and  muco-purulent  sputa. 
The  prominence  of  the  cough  and  the  characters  which  the  expec- 
toration presents,  will  serve  to  indicate,  on  the  one  hand,  merely 
congestion  and  irritation  of  the  bronchial  membrane,  or,  on  the 
other  hand,  a  superinduced  pulmonary  affection.  The  existence 
and  nature  of  the  latter,  however,  are  to  be  ascertained,  not  by  the 
cough  and  expectoration  alone,  but  by  means  of  other  associated 


HEMOPTYSIS.  159 

symptoms  and  by  physical  signs.  The  accumulation  of  liquid 
within  the  bronchial  tubes  often  increases  the  dyspnoea,  and,  at  an 
advanced  period,  may  prove  the  immediate  cause  of  death  by 
asphyxia. 

Haemoptysis  is  a  symptom  which  occurs  in  a  pretty  large  pro- 
portion of  cases  of  valvular  lesions  attended  with  a  marked  degree 
of  engorgement  of  the  lungs.  It  is  due  to  distension  of  the  vessels 
of  the  bronchial  membrane;  diminished  cohesion  from  impaired 
nutrition  eventuating  in  rupture  at  certain  points.  The  amount  of 
hemorrhage  varies  in  different  cases.  It  is  rarely  large,  and  often 
quite  small.  In  some  instances,  frequent  repetitions  of  the  haamo- 
ptysis  take  place.  It  is  rare  that  the  loss  of  blood  is  sufficient  to 
constitute  grounds  for  apprehension,  although  this  symptom  gene- 
rally occasions  alarm  in  the  minds  of  patients  and  friends.  The 
immediate  effect  is  perhaps  oftener  salutary  than  otherwise,  the 
pulmonary  congestion  being  temporarily  relieved  by  the  direct 
depletion  from  the  engorged  vessels.  Of  the  different  lesions,  mitral 
contraction  is  most  likelj''  to  give  rise  to  bronchial  hemorrhage.  It 
occurs,  however,  by  no  means  exclusively  in  connection  with  this 
form,  but  is  observed  in  cases  of  mitral  regurgitation,  and  also  in 
connection  with  lesions  at  the  aortic  orifice.  It  was  formerly 
attributed  incorrectly  to  hypertrophy  of  the  right  ventricle,  the 
augmented  power  of  the  contraction  of  this  ventricle  being  sup- 
posed to  impel  the  current  of  blood  into  the  pulmonary  vessels 
v/ith  a  force  sufficient  to  produce  rupture.  It  is  not  probable  that 
this  alone  is  ever  adequate  to  give  rise  to  haemoptysis,  but  it  is 
reasonable  to  suppose  that  it  may  exert  some  agency  in  conjunction 
with  the  valvular  lesions  which  occasion  obstruction  at  the  left  side 
of  the  heart.  Dilatation  of  the  right  ventricle,  however,  by  retard- 
ing the  circulation  through  the  lungs,  probably  co-operates  with 
the  valvular  lesions  in  the  production  of  this  symptom,  more  than 
hypertrophy  of  this  ventricle. 

Hemorrhagic  extravasation,  pneumorrhagia,  or  pulmonary  apo- 
plexy, involves  the  same  pathological  explanation  as  haemoptysis, 
but  occurs  much  more  unfrequently  than  the  latter.  It  is  a]i  occa- 
sional effect  of  engorgement.  In  most  of  the  cases  in  which  it 
occurs,  there  exists  mitral  contraction.  This  pulmonary  affection 
is  very  rarely  observed  except  in  connection  with  valvular  lesions 
which  give  rise  to  obstruction  at  the  left  side  of  the  heart.  As 
regards  the  agency  of  hypertrophy  of  the  right  ventricle  in  its  pro- 
duction, the  remarks  made  with  reference  to  haemoptysis  are  alike 


160      LESIONS    AFFECTIXG    THE    VALVES    OF    THE    HEART. 

applicable.  Ilfcmoptysis  and  hemorrhagic  extravasation  occasion- 
ally co-exist,  but  the  latter,  as  well  as  the  former,  occurs  without 
the  other.  In  proportion  to  the  extent  of  solidification  of  lung  by 
the  extravasated  blood,  will  the  respiratory  function  be  compro- 
mised, and  dyspnoea  increased.  The  symptoms  and  signs  pertaining 
to  this  affection  will,  of  course,  be  superadded  to  those  which  belong 
to  pulmonary  congestion.  For  the  diagnostic  points,  which  are, not 
highly  distinctive,  the  reader  is  referred  to  works  treating  of  dis- 
eases of  the  respiratory  system. 

Pulmonary  oedema  is  another  pathological  effect  attributable 
directly  to  over-distension  of  the  vessels  of  the  lungs.  This  event 
takes  place  much  more  frequently  than  extravasation  of  blood. 
The  liability  to  its  occurreace,  other  things  being  equal,  is  propor- 
tionate to  the  amount  of  obstruction  at  the  left  side  of  the  heart ; 
but  it  is  more  likely  to  occur  when  dilatation,  or  weakness  of  the 
right  ventricle  is  superadded.  A  condition  of  the  blood  disposiug 
to  transudation  favors  its  occurrence.  When  such  a  condition 
exists,  cedema  of  the  lungs  occurs  in  connection  with  effusion  in 
other  situations,  or  general  dropsy.  Occurring  alone,  or  irrespective 
of  dropsical  effusion  elsewhere,  it  belongs  among  the  events  incident 
to  an  advanced  stage  of  valvular  lesions.  It  adds  to  the  dyspnoea 
in  proportion  to  the  amount  of  pulmonary  parenchyma  involved, 
and  also  increases  the  cough  and  expectoration.  In  a  certain  pro- 
portion of  cases  it  proves  the  immediate  cause  of  death  by  asphyxia. 
Its  occurrence  is  denoted  by  physical  signs  (dulness  on  percussion 
and  the  subcrepitant  or  a  fine  mucous  rale),  which  generally  render 
practicable  the  diagnosis. 

The  symptoms  and  pathological  effects  which  have  been  noticed, 
it  will  be  borne  in  mind,  are  produced  by  valvular  lesions  through 
the  intervention  of  the  pulmonary  engorgement  incident  to  these 
lesions.  They  are  immediate  effects  of  this  engorgement.  Valvular 
lesions,  therefore,  may  exist  without  giving  rise  to  these  eff!ects,  so 
long  as  the  lesions  do  not  interfere  materially  with  the  pulmonary 
circulation.  It  does  not  follow  from  the  fact  that  there  is  abundant 
evidence  of  the  existence  of  valvular  lesions,  that  these  symptoms 
and  effects  will  speedily  occur,  for  lesions  may  exist  for  an  indefinite 
period  without  occasioning  a  marked  degree  of  congestion  of  the 
lungs.  Moreover,  the  pulmonary  circulation  bears  with  impunity 
a  certain  amount  of  obstruction.  As  a  rule,  whenever  events  of 
importance  referable  to  the  respiratory  system  become  developed, 
valvular  lesions  have  existed  for  a  considerable  length  of  time,  and 


PULMONARY    AFFECTIONS.  161 

have  led  to  more  or  less  enlargement  of  the  heart.  The  heart, 
when  enlarged,  with  or  without  lesions  of  the  valves,  encroaches  on 
space  which  otherwise  would  have  been  occupied  bj  the  lungs.  In 
this  way  the  respiratory  function  is  to  some  extent  compromised. 
I  have  met  with  instances  of  collapse  of  the  lower  lobe  of  the  left 
lung,  apparently  due  to  the  pressure  of  an  enlarged  heart. 

Certain  pulmonary  affections  not  due  directly  or  exclusively  to 
the  congestion  proceeding  from  valvular  lesions,  are  more  apt  to 
occur  under  these  circumstances,  than  if  the  latter  did  not  exist. 
The  lesions  thus  indirectly  predispose  to  the  development  of  these 
affections.  Emphysema  of  the  lungs  is  one  of  these  aflections. 
This  is  certainly  observed  among  a  given  number  of  persons 
affected  with  valvular  lesions,  in  a  larger  ratio  than  among  the 
same  number  of  persons  free  from  these  lesions.  Without  enterino- 
into  a  discussion  of  the  mechanism  by  which  pulmonary  emphy- 
sema is  produced,  which  would  be  here  out  of  place,  I  shall  simply 
remark  that  the  histories  of  cases  in  which  this  affection  is  developed 
during  the  progress  of  valvular  lesions  show  that  it  is  preceded  and 
accompanied  by  bronchitis,  to  which  it  probably  sustains  the  same 
relation  as  when  it  is  developed  irrespective  of  cardiac  disease. 
Occurring  as  a  complication  of  valvular  lesions,  it  adds  notably  to 
the  dyspnoea,  overshadowing  in  some  instances  the  cardiac  symp- 
toms. Moreover,_  increasing  the  obstruction  to  the  pulmonary 
circulation,  it  co-operates  with  the  impediment  due  to  the  valvular 
lesions  in  leading  to  enlargement  of  the  right  ventricle.  It  is  not 
easy  in  individual  cases  always  to  determine  the  amount  of  dyspnoea 
and  other  symptoms  attributable,  on  the  one  hand,  to  the  emphy- 
sema, and,  on  the  other  hand,  to  the  congestion  incident  to  valvular 
lesions.  This  problem  can  only  be  solved  approximately  by  endea- 
voring to  estimate  the  extent  to  which  the  lungs  are  emphysema- 
tous, by  means  of  diagnostic  signs  which  it  belongs  to  works 
treating  of  diseases  of  the  respiratory  system  to  consider,  and  also 
ascertaining  the  amount  of  cardiac  enlargement  which  exists. 

The  congested  state  of  the  bronchial  mucous  membrane  renders 
it  prone  to  inflammation.  Bronchitis  is  a  frequent  complication  of 
valvular  lesions  after  they  have  induced  pulmonary  engorgement. 
This  complication  occurring  in  persons  free  from  antecedent  disease 
of  the  lungs  or  heart,  and  limited,  as  is  usually  the  case,  to  the 
larger  tubes,  very  rarely  gives  rise  to  dyspnosa.  But  developed 
when  the  lungs  are  already  congested  in  connection  with  cardiac 
lesions,  dyspnoea  becomes  more  or  less  prominent.  The  existence 
11 


162      LESIONS    AFFECTING    THE    VALVES    OF    THE    HEAKT. 

of  bronchitis,  disconnected  from  other  pulmonary  affections,  is 
determined  by  its  positive  symptoms  and  signs,  and  by  the  absence 
of  the  diagnostic  phenomena  which  characterize  other  affections. 
The  coexistence  of  bronchitis  not  only  adds  to  the  distress  incident 
to  valvular  lesions  which  interfere  with  the  pulmonary  circulation, 
but,  if  severe  or  extensive,  often  places  the  patient  in  immediate 
danger,  the  accumulation  of  the  products  within  the  bronchial 
tubes,  together  with  the  diminished  calibre  of  the  tubes  from  swell- 
ing of  the  membrane,  inducing  suffocation.  In  some  persons  the 
bronchial  inflammation  leads  to  spasm  of  the  muscular  fibres  of 
the  membrane,  giving  rise  to  attacks  of  true  asthma.  As  already 
stated,  it  is  probably  by  the  intervention  of  bronchitis  that  valvular 
lesions  predispose  to  emphysema. 

Persons  affected  with  valvular  lesions  which  have  led  to  pul- 
monary congestion,  are  more  prone  than  others  to  pneumonitis. 
The  affection  occurring  in  this  connection  is  attended  with  much 
greater  embarrassment  of  respiration,  and  disturbance  of  the  circu- 
lation, than  when  it  occurs  as  a  primary  disease;  and  it  is  more 
likely  to  prove  fatal.  Death  sometimes  occurs  during  the  first 
stage  of  the  disease,  which  is  very  rarelj^  the  case  when  pneumonitis 
is  primitive.  The  characteristic  symptoms  and  signs  of  the  affection 
render  the  fact  of  its  coexistence,  in  individual  cases,  easily  deter- 
minable. 

Dropsical  effusion  into  the  pleural  sacs  rarely  occurs  to  much 
extent  independently  of  general  dropsy.  When  it  does  take  place, 
the  compression  of  the  lungs  by  the  effused  liquid  abridges  their 
functional  capacity,  aggravates  the  dyspncea,  and  hastens  a  fatal 
issue.  The  effusion,  when  purely  dropsical,  exists  in  both  sides  of 
the  chest;  the  quantity  in  one  side,  however,  often  exceeding  con- 
siderably that  in  the  other  side.  But,  in  a  certain  proportion  of 
cases,  pleuritic  inflammation  becomes  developed  in  one  side,  giving 
rise  to  an  abundant  effusion  of  liquid,  nearly  or  quite  filling  the 
affected  side.  In  several  instances  which  have  fallen  under  my 
observation,  pleurisy  has  occurred  when  the  cardiac  affection  had 
not  previously  occasioned  sufficient  inconvenience  to  prevent  the 
patients  from  continuing  laborious  occupations.  The  inflamma- 
tion is  subacute.  The  affection  is  developed,  as  cases  of  chronic 
pleurisy  frequently  are,  with  little  or  no  pain,  the  chief  subject  of 
complaint  being  dyspnoea.  So  slight  are  the  symptoms  referable 
to  the  lungs,  exclusive  of  dyspnoea,  that  if  the  attention  of  the 
physician  be  directed  to  the  heart,  there  is  a  liability  of  overlooking 


SYMPTOMS    REFERABLE    TO    NERVOUS    SYSTEM.  163 

the  pleuritic  effusion,  unless  pains  are  taken  to  explore  the  chest 
for  the  sierns  of  this  affection.     On  examination  after  death  the 

O 

liquid  effused  is  not  transparent  as  in  cases  of  hydrothorax,  but  not 
notably  turbid,  and  the  solidified  fibrin,  or  lymph,  is  not  abundant. 
The  inflammatory  action  has  a  low  grade  of  intensity.  This  is 
true  of  the  instances  that  have  come  under  my  observation.  The 
effused  liquid  is  less  likely  to  be  removed  by  absorption  than  in 
cases  in  which  chronic  pleurisy  is  not  connected  with  valvular 
lesions.  A  fatal  termination  is  hastened  by  this  complication,  and 
in  some  instances  death  takes  place  very  soon  after  its  occurrence. 
The  physical  signs  of  an  abundant  pleuritic  effusion  are  so  simple 
and  well  marked,  that  if  overlooked  by  those  who  avail  themselves 
of  physical  exploration  of  the  chest,  it  must  be  from  inattention. 
Chronic  pleurisy  is  developed  in  some  cases  in  which  valvular 
lesions  are  associated  with  albuminuria  and  Bright's  disease,  but 
it  occurs  when  the 'kidneys  are  free  from  disease. 


Symptoms  and  Pathological  Effects  referable  to  the  Nervous 

System. 

The  majority  of  cases  of  valvular  lesions  end  without  having 
given  rise  to  prominent  symptoms  or  important  pathological  effects 
referable  to  the  nervous  system.  This  statement  is  at  variance 
with  the  notions  generally  entertained  and  inculcated  by  some 
writers.  It  is  a  common  impression  that  various  symptoms  denot- 
ing cerebral  disorder,  such  as  cephalalgia,  vertigo,  tinnitus  aurium, 
muscse  volitantes,  etc.  etc.,  are  usually  observed,  sooner  or  later, 
during  the  progress  of  cardiac  disease.  These  symptoms  are  often 
observed  in  persons  not  affected  with  disease  of  the  heart,  and,  hence, 
would  possess  small  diagnostic  significance  were  they  more  fre- 
quently present;  but,  the  truth  is,  they  occur  in  only  a  small  pro- 
portion of  cases,  at  least  in  a  marked  degree.  Apoplexy  and 
paralysis  are  events  much  less  common  than  is  generally  supposed. 
It  is  then  hardly  necessary  to  consider  at  much  length  the  mooted 
question,  whether  cerebral  phenomena  and  complications  proceed 
from  the  abnormal  power  of  an  hypertrophied  left  ventricle,  or 
from  the  obstruction  occasioned  by  over-distension  of  the  right 
auricle.  It  is  conceivable  that  either  and  both  may  conduce,  in 
certain  instances,  to  congestion,  extravasation  of  blood,  and  serous 
transudation;  but  clinical  facts  show  that,  separately  or  combined, 


164      LESIONS    AFFECTING    THE    VALVES    OF    THE    HEART. 

they  very  rarely  produce  disorder  of  the  cerebral  circulation  suffi- 
cient to  occasion  great  inconvenience  to  the  patient  or  lead  to  serious 
results.  Of  seventy-two  fatal  cases  of  lesions  affecting  the  mitral 
and  aortic  orifices,  one  or  both,  which  I  have  analyzed  with  refer- 
ence to  this  point,  the  histories  of  fifty-five  present  no  symptoms  or 
events  of  importance  pertaining  to  the  brain. 

Yalvular  lesions,  accompanied  by  enlargement  of  the  heart,  have 
been  supposed  to  involve  a  strong  liability  to  apoplexy.  This 
opinion  was  held  by  Hope.  Apoplexy  occurs  in  a  small  propor- 
tion of  cases  of  valvular  disease.  Of  the  seventy-two  cases  analyzed 
it  took  place  in  seven.  But  even  in  the  few  cases  in  which  apoplexy 
and  valvular  lesions  are  associated,  circumstances  go  to  show  that 
there  often  exists  only  a  remote  and  contingent  pathological  con- 
nection between  them.  Of  the  seven  cases  just  mentioned,  the  age 
of  the  patients  in  all,  save  one,  was  over  forty  years.  In  one,  it 
was  eighty,  in  one,  sixty-six,  in  one,  fifty-five,  and  in  one,  fifty-two. 
The  ages  were  within  the  period  when  apoplexy,  irrespective  of 
heart  disease,  is  most  apt  to  occur.  In  some  of  the  cases,  the 
cerebral  arteries  were  found  to  have  become  calcified.  In  one  of 
the  cases,  the  patient  being  forty-one  years  of  age,  the  valvular 
afiection  was  trivial,  accompanied  by  slight  enlargement.  It  is  not 
unfrequently  the  case  when,  from  the  coincidence  of  apoplexy  and 
some  morbid  appearances  of  the  valves,  the  former  is  supposed  to 
be  dependent  on  the  latter,  that  the  valvular  lesions  are  not  suffi- 
cient to  have  occasioned  much  disturbance  of  the  circulation.  On 
the  other  hand,  how  rarely  does  apoplexy  occur  when  there  exists 
over-distension  and  dilatation  of  the  right  auricle,  together  with 
considerable  hypertrophy  of  the  left  ventricle !  In  view  of  these 
facts,  it  is  reasonable  to  conclude  that  apoplexy  is  very  rarely  due, 
directly  or  exclusively,  to  the  condition  of  the  heart,  but  that  the 
changes  which  the  cerebral  vessels  undergo,  or  other  circumstances, 
generally  play  an  important  part  in  its  production.  This  is  not  to 
deny  more  or  less  agency  to  the  heart  in  certain  cases.  And  of  the 
two  conditions  which  tend  directly  to  affect  the  circulation  in  the 
brain,  viz :  obstruction  at  the  right  side  of  the  heart,  and  hyper- 
trophy of  the  left  ventricle,  the  former  must  be  considered  as  most 
likely  to  lead  to  serious  results.  Hypertrophy  of  the  left  ventricle 
is  generally  associated  either  with  obstruction  or  regurgitation  at 
the  aortic  or  mitral  orifice.  An  efi'ect  of  each  of  these  different 
lesions  is  either  to  diminish  the  quantity  of  blood  sent  to  the  brain, 
or  to  break  the  force  of  the  ventricle  upon  the  arterial  current. 


APOPLEXY.  165 

The  latter  obtains  when  the  aortic  orifice  is  contracted,  and  the 
former  in  cases  of  aortic  regurgitation  and  of  mitral  lesions,  whether 
obstructive  or  regurgitant.  The  opinion  held  by  Hope  and  others 
that  apoplexy  sustains  a  direct  pathological  connection  with  hyper- 
trophy of  the  left  ventricle,  is  disproved  on  rational  grounds  as  well 
as  by  clinical  evidence. 

Apoplexy  occurring  in  connection  with  cardiac  lesions  generally 
depends  on  extravasation  of  blood.  Under  these  circumstances, 
paralysis,  of  course,  ensues.  If  the  apoplectic  attack  do  not  prove 
suddenly  fatal,  the  patient  is  found  to  be  hemiplegic.  Paralj'sis 
sometimes  occurs  without  being  preceded  by  apoplexy.  Either  or 
both  may  proceed  from  a  cause  emanating  from  the  heart,  inde- 
pendently of  either  an  impediment  at  the  right  auricle  or  hyper- 
trophy of  the  left  ventricle.  Reference  is  now  made  to  an  event 
which  has  been  already  noticed  under  the  head  of  pathological 
effects  referable  to  the  circulation,  viz.,  detached  fibrinous  deposits 
or  emboli.  It  appears  to  bfe  sufliciently  established  that  these 
sometimes  become  fixed  in  the  arterial  trunks  of  the  brain,  and 
give  rise  to  apoplectic  seizures  with  or  without  paralysis,  or  to  the 
latter  without  the  former.  In  this  way,  valvular  lesions  may  sus- 
tain towards  these  cerebral  affections  a  direct  causative  relation. 
This  explanation  of  apoplexy  and  paralysis  associated  with  valvu- 
lar lesions  is  rendered  probable  in  cases  in  which,  from  the  age  of 
the  patient,  fatty  or  calcareous  degeneration  of  the  cerebral  arteries 
is  not  likely  to  have  occurred,  and  when  there  does  not  exist  a 
notable  degree  of  obstruction  at  the  right  side  of  the  heart.  After 
death,  this  is  to  be  suspected  when  the  aortic  or  mitral  valves  are 
found  to  present  vegetations  or  excrescences,  some  of  which  are 
loosely  attached.  The  proof  consists  in  finding  deposits  or  emboli 
impacted  in  one  or  more  of  the  arterial  trunks  of  the  brain,  which 
are  found,  on  microscopical  examination,  to  have  the  same  compo- 
sition and  interior  arrangement  as  coexisting  deposits  on  the  valves 
of  the  left  side  of  the  heart.  Complete  recovery  from  paralysis  is 
a  ground  for  suspecting  that  it  originated  in  arterial  obstraction 
rather  than  in  extravasation,  the  restoration  of  power  over  the 
paralyzed  muscles,  when  the  latter  occurs,  being  rarely  perfect. 

Arterial  obstruction  is  supposed  to  give  rise  to  apoplectic  phe- 
nomena and  paralysis  by  lessening  the  supply  of  blood  to  certain 
portions  of  the  cerebral  substance.  The  pathological  condition 
induced,  therefore,  is  the  opposite  of  that  incident  to  an  impediment 
to  the  circulation  at  the  right  side  of  the  heart.     In  the  one  case 


106      LESIONS   AFFECTING    THE    VALVES    OF    THE    HEAET. 

a  part  of  the  brain  suffers  from  ancemia,  in  the  other  case  the 
whole  brain  is  congested.  Softening  of  the  cerebral  substance  has 
been  observed  in  connection  with  the  interruption  of  the  circula- 
tion by  fibrinous  plugs  or  emboli,  attributable  to  impaired  nutri- 
tion from  the  defective  supply  of  blood.  Dr.  Law,  of  Dublin 
attaches  considerable  importance  to  the  defective  supply  of  blood 
to  the  whole  brain  as  a  result  of  either  mitral  or  aortic  obstruction. 
In  these  lesions  more  especially,  but  to  a  considerable  extent  also 
in  those  attended  by  regurgitation,  the  stream  of  blood  propelled 
into  the  aorta  and  cerebral  arteries  is  obviously  lessened.  The 
brain  receives  with  each  contraction  of  the  left  ventricle  a  quantity 
of  blood  less  than  when  the  valves  and  orifices  are  free  from 
disease.  Dr.  Law  attributes  cerebral  softening  in  some  instances 
to  this  cause.'  The  importance  attached  by  this  writer,  however, 
to  an  anaemic  state  of  the  brain,  as  thus  induced,  is  hot  sustained 
by  clinical  observation,  since  it  is  only  in  a  small  proportion  of  the 
cases  attended  with  more  or  less  obstruction  or  regurgitation,  or 
both,  at  either  the  aortic  or  mitral  orifice,  that  cerebral  S3'mptoms 
denoting  any  important  pathological  condition  are  manifested. 
Cases  of  extreme  aortic  and  mitral  contraction  proceed  to  a  fatal 
termination,  the  histories  not  containing  aught  which  indicates 
that  the  brain  has  suffered  from  a  deficient  supply  of  blood. 

Attacks  of  pseudo-apoplexy,  that  is,  of  coma,  more  or  less  com- 
plete, continuing  for  a  certain  period  and  passing  off  without 
paralysis,  have  been  observed  in  cases  of  valvular  lesions.  They 
have  been  already  described  in  treating  of  fiitty  degeneration  of  the 
heart.  They  may  depend  on  the  latter  change  coexisting  with 
valvular  lesions;  but,  as  remarked  in  connection  with  the  subject 
of  fatty  degeneration,  the  pathological  relation  between  these 
attacks  and  the  existence  of  any  organic  disease  of  the  heart  cannot 
be  considered  as  established. 

Aside  from  apoplexy  and  paralysis,  the  various  symptoms  already 
mentioned,  viz.,  pain,  vertigo,  tinnitus,  etc.,  are  occasionally  asso- 
ciated with  valvular  lesions.  Apoplexy  and  paralysis  depending 
either  on  an  extravasation  which  involves  a  morbid  condition  of 
the  cerebral  vessels,  or  on  arterial  obstruction  from  emboli,  are 
usuall}^  not  preceded  by  premonitions  referable  to  the  brain.  Clini- 
cal observation  shows  that  a  liability  to  these  affections  is  not  to  be 
predicated  on  the  symptoms  just  referred  to.     This  is  a  practical 

'  Dublin  Journal  of  Medicine,  May,  1840. 


SLEEP    AND    MENTAL    CONDITION.  167 

point  to  be  borne  in  mind  in  order  that  gratuitous  apprehensions 
need  not  be  entertained  on  the  part  of  physician  or  patient,  and 
measures  employed,  with  a  view  of  warding  off  an  attack  of  apo- 
plexy or  paralysis,  which,  being  uncalled  for,  will  be  likely  to  be 
not  only  unnecessary,  but  injudicious.  In  the  cases  in  which  there 
must  be  more  or  less  cerebral  congestion,  the  superficial  veins  of 
the  neck  being  swelled  or  pulsating,  marked  cerebral  symptoms 
are  not  uniformly  present.  Headache,  dulness  of  the  intellect, 
listlessness,  drowsiness,  etc.,  are  symptoms  which,  in  a  certain  pro- 
portion of  cases  of  this  description,  are  more  or  less  marked,  and 
are  probably  due  to  abnormal  fulness  of  the  cerebral  veins.  These 
symptoms  of  cerebral  oppression  are  sometimes  marked  in  cases  in 
which,  either  from  obstruction  at  the  right  side  of  the  heart  or 
imperfect  oxygenation  of  the  blood,  the  prolabia  and  surface  of  the 
body  present  a  livid  appearance. 

The  sleep  of  patients  affected  with  cardiac  disease  is  frequently 
imperfect.  They  complain  sometimes  of  frightful  dreams.  This  is 
generally  associated  with  dyspncea,  and  appears  to  be  owing  to 
disturbed  respiration  rather  than  to  disordered  cerebral  circulation. 
Moaning  in  sleep  is  a  symptom  observed  in  some  cases,  Avhen  the 
patient  is  not  wakeful  nor  conscious  of  any  morbid  sensations. 

A  sj^mptom  which  may  be  included  among  the  events  referable 
either  to  the  nervous  or  respiratory  system,  is  noticed  in  some  cases, 
viz  :  a  choking  sensation  analogous  to  that  experienced  in  painful 
emotions  when  an  effort  is  made  to  refrain  from  weeping.  This  is 
not  of  frequent  occurrence,  but  it  has  been  prominent  in  several 
instances  among  the  cases  that  have  come  under  my  observation. 
It  is  associated  with  more  or  less  dyspncea. 

The  mental  condition  of  patients  affected  with  organic  disease  of 
heart,  may  be  noticed  in  this  connection.  The  contrast  presented 
in  this  respect,  with  patients  affected  with  merely  functional  dis- 
order, has  been  already  referred  to.  Persons  with  organic  disease 
which  has  given  rise  to  grave  symptoms,  such  as  palpitation,  dys- 
pnoea, dropsy,  etc.,  are  generally  free  from  excitement  and  appre- 
hension. They  often  seem  to  be  remarkably  indifferent  or  apathetic. 
They  are  not  agitated  when  made  acquainted  with  the  fact  that 
they  have  organic  disease  of  the  heart.  They  are  sometimes  incredu- 
lous as  to  the  seat  of  the  disease,  and  are  disposed  to  attribute  their 
ailments  to  the  liver,  lungs,  or  stomach.  The  mental  condition,  in 
short,  is  quite  the  reverse  of  that  usually  associated  with  affections 
purely  functional.     It  is  not  unlike  that  which  exists  in  connection 


163      LESIOXS    AFFECTING    THE    VALVES    OF    THE    HEART. 

with  pulmonary  tuberculosis.  A  comparison  of  the  characters  per- 
taining to  the  feelings,  which  belong  to  the  history  of  organic  lesions 
of  the  heart,  with  those  observed  in  some  other  diseases,  affords  a 
striking  illustration  of  the  great  difference  in  the  effects  produced 
on  the  mind  by  different  morbid  conditions  irrespective  of  cerebral 
diseases. 

Some  degree  of  mental  aberration  is  occasionally  observed 
toward  the  close  of  life  in  cases  of  valvular  lesions,  but  delirium 
cannot  be  reckoned  among  the  events  belonging  to  their  natural 
history. 


SyIMPTOMS   AND   PATHOLOGICAL  EFFECTS  REFERABLE   TO   THE   DIGESTIVE 

System  and  Nutrition. 

The  phenomena  manifested  in  connection  with  the  digestive 
apparatus  in  cases  of  valvular  lesions,  proceed  from  congestion  of 
the  systemic  venous  system.  Assuming  the  lesions  to  be  either 
mitral  or  aortic,  or  both,  congestion  of  this  order  of  vessels  depends 
on  the  effects  of  these  lesions  on  the  right  side  of  the  heart.  It 
may  be  stated  that,  as  a  rule,  the  systemic  congestion  is  not  suf- 
ficient to  give  rise  to  important  symptoms  or  pathological  effects 
until  dilatation  of  the  right  ventricle  has  taken  place,  involving  over- 
distension of  the  right  auricle,  and,  in  certain  instances,  tricuspid 
regurgitation.  The  impediment  to  the  free  admission  of  blood 
from  the  veufe  cavte  into  the  right  auricle,  occasions  cerebral  conges- 
tion, as  has  just  been  seen.  The  congestion  throughout  the  body 
thus  induced,  as  has  also  been  seen,  gives  rise  to  venous  turges- 
cence  and  general  dropsy.  The  abdominal  viscera  indirectly  par- 
ticipate in  the  effects  of  this  impediment  at  the  right  ventricle, 
owing  to  their  vascular  relations  to  the  venae  cav^e  being  through 
the  intervention  of  the  portal  system.  In  view  of  the  anatomical 
peculiarities  of  the  latter,  it  is  obvious  that,  of  the  organs  com- 
prising the  abdominal  viscera,  the  liver  is  first  affected  by  an 
obstruction  at  the  right  side  of  the  heart.  The  radicles  of  the 
hepatic  veins  (the  intra-lobular  veins)  are  the  first  of  the  dif- 
ferent orders  of  vessels  contained  in  this  viscus,  to  show  engorge- 
ment. The  terminal  branches  of  the  portal  vein  (the  inter-lobular 
veins)  are  next  affected.  The  appearances  after  death  indicate 
whether  either  or  both  of  these  sets  of  vessels  are  unduly  congested. 
The  pressure  of  the  portal  branches,  or  interlobular  veins,  on  the 


PORTAL    CONGESTION.  169 

biliary  tubes  may  occasion  an  undue  accumulation  of  bile  in  the 
latter.  Sections  of  the  organ  then  present  that  peculiar  aspect 
commonly  known  as  the  "  nutmeg  liver."  Extending  beyond  the 
liver  to  the  portal  vein  and  its  radicles,  the  congestion  affects  finally 
the  stomach  and  intestines,  the  spleen  and  the  pancreas.  Conges- 
tion of  these  organs  is  a  secondary  effect  due  directly  to  the  me- 
chanical obstacle  to  the  passage  of  blood  through  the  liver.  The 
successive  steps,  thus,  in  the  series  of  congestive  efi'ects  dependent 
on  valvular  lesions  are  :  Obstruction  or  regurgitation  at  either  the 
mitral  or  aortic  oriiice,  or  at  both  situations ;  dilatation  of  the  right 
ventricle  following  engorgement  of  the  pulmonary  vessels  ;  over- 
distension of  the  right  auricle,  with  or  without  tricuspid  regurgita- 
tion, involving  an  impediment  to  the  free  transmission  of  blood 
from  the  ven^e  cav^e ;  congestion  of  the  hepatic  vein,  and  its  radi- 
cles, the  intra-lobular  veins;  congestion  of  the  terminal  branches 
of  the  portal  vein,  or  the  inter-lobular  veins ;  congestion  of  the 
vena  portge  and  its  radicles  in  the  abdominal  viscera  which  furnish 
the  blood  for  the  portal  circulation. 

Clinical  observation  shows,  as  might  rationally  be  anticipated, 
that  the  phenomena  due  to  engorgement  of  the  abdominal  viscera, 
are  developed,  in  the  order  of  time,  consecutively  to  the  general 
effects  of  congestion  of  the  systemic  veins.  It  is  rarely  the  case 
that  the  former  occur  to  much  extent  until  the  obstruction  at  the 
right  side  of  the  heart  is  sufficient  to  give  rise  to  more  or  less 
general  dropsy.  As  a  general  remark,  symptoms  and  pathological 
effects  referable  to  the  digestive  system  do  not  hold  a  prominent 
place  among  the  events  which  belong  to  the  natural  history  of 
valvular  lesions.  This  statement  is  made  after  analyzing  the  histo- 
ries of  one  hundred  cases,  extending  in  seventy  to  the  period  of 
death.  In  a  large  majority  of  these  histories,  nothing  of  importance 
was  noted  with  reference  to  the  digestive  system. 

Enlargement  of  the  liver  is  an  occasional  effect  incident  to  valvu- 
lar lesions,  as  well  as  to  enlargement  of  the  heart,  uncomplicated 
with  the  latter.  This  has  been  already  noticed  in  connection  with 
the  subject  of  enlargement  of  the  heart.  It  is  more  correct  to  say 
tliat  this  is  an  effect  of  enlargement  aff'ectino:  the  ris-ht  side  of  the 
heart,  either  with  or  without  the  coexistence  of  valvular  lesions,  the 
latter  inducing  the  effect  through  the  intervention  of  the  cardiac 
enlargement,  as  has  just  been  stated.  The  augmented  size  of  the 
liver  is  in  some  instances  remarkable,  and  its  variations  in  size  at 


170      LESIONS    AFFECTING    THE    VALVES    OF    THE    HEART, 

different  periods  is  not  less  striking.  The  enlargement  is  due 
simply  to  the  excessive  accumulation  of  blood  in  the  vessels  of  the 
organ.  Jaundice  is  an  occasional  symptom.  It  is  met  with,  how- 
ever, in  a  very  small  proportion  of  cases. 

Cirrhosis,  contrary  to  a  common  impression,  is  not  a  frequent 
complication  of  valvular  affections  of  the  heart.  The  congested 
state  of  the  liver  incident  to  these  affections  does  not  seem  to  tend 
to  its  production.  The  concurrence  of  these  affections  and  this 
structural  change  of  the  liver  is  so  infrequent,  as  hardly  to  afford 
ground  for  the  opinion  that  there  exists  between  the  two  any 
pathological  connection.  When  associated,  it  is  probably  simply 
a  coincidence.  M.  Becquerel  reported  the  existence  of  cardiac  dis- 
ease in  twenty-one  of  forty-two  cases  of  cirrhosis  which  he  analyzed, 
the  former  being  deemed  to  have  occurred  prior  to  the  latter.'  But 
in  more  than  one-half  of  the  twenty-one  cases,  he  regarded  the 
cirrhosis  as  in  the  first  degree  giving  rise  to  no  symptoms  of  im- 
portance. These  statistics,  as  remarked  by  Dr.  Budd,  are  to  be 
accounted  for  on  the  supposition  that  the  abnormal  appearances  due 
to  congestion  of  the  different  sets  of  vessels  were  confounded  with 
the  commencement  of  cirrhosis.  The  symptom  denoting  coexist- 
ing cirrhosis,  is  ascites  in  a  degree  disproportionate  to  the  general 
dropsy.  So  far,  however,  from  there  being  often  a  preponderance 
of  ascites,  it  is  generally  less  than  the  relative  amount  of  dropsical 
effusion  into  the  pleural  cavities  in  cases  of  valvular  lesions  of  the 
heart. 

The  various  phenomena  included  in  the  term  indigestion,  which 
are  common  to  a  great  number  of  affections,  may  be  absent  or 
present,  and  more  or  less  prominent  in  cases  of  valvular  lesion?. 
But  in  a  large  proportion  of  cases  they  do  not  occur  in  a  marked 
degree,  at  least  during  the  greater  portion  of  the  time  occupied  by 
the  progress  of  the  lesions  before  a  fatal  issue  takes  place.  Patients 
who  suffer  from  the  distressing  effects  of  obstructive  or  regurgitant 
lesions,  together  with  enlargement  of  the  heart,  often  preserve  their 
appetite,  and  the  ingestion  of  food  occasions  no  inconvenience. 
This,  in  fact,  is  usually  the  case,  so  that  disordered  digestion  cannot 
be  considered  to  characterize  organic  affections  of  the  heart".  The 
disorders  which  are  observed  in  an  advanced  stage,  after  general 
dropsy  has  taken  place,  are  probably  due,  in  part  at  least,  to  con- 

'  Archives  Generales  de  Medecine,  1840.  Budd  on  Diseases  of  the  Liver,  secoud 
Am.  ed.,  p.  148. 


HEMORRHAGES.  —  NUTRITION.  171 

gestiou  of  the  gastric  mucous  membrane.  HEematemesis  is  one  of 
the  rare  effects,  occurring  sometimes  when  cirrliosis  of  the  liver 
does  not  coexist. 

Intestinal  flux,  or  enterorrhoea,  is  another  infrequent  symptom, 
the  serous  transudation  taking  a  direction  throug-h  the  raucous 
tissue,  instead  of,  or  in  addition  to  the  more  common  direction  into 
the  peritoneal  cavity. 

Hemorrhage  from  the  bowels  is  to  be  ranked  in  the  same  cote- 
gory.  The  same  is  to  be  said  of  haemorrhoids.  In  this  connection 
may  be  mentioned  epistaxis,  which  occurs  more  frequently,  as  a 
result  of  obstruction  at  the  right  side  of  the  heart,  than  hemorrhage 
in  any  other  situation.  It  is  supposed  that  the  escape  of  blood 
from  the  nostrils  may  in  some  instances  prevent  extravasation  into 
the  brain,  or  other  serious  effects  of  cerebral  congestion,  by  relieving 
the  vessels,  in  a  measure,  of  their  over-accumulation. 

Enlargement  of  the  spleen,  due  exclusively  to  the  congestion  of 
the  portal  sj'stem  dependent  on  cardiac  obstruction,  must  be  ex- 
ceedingly rare.  It  is,  however,  to  be  reckoned  among  the  effects 
which  are  occasionally  observed. 

The  functions  of  nutrition,  applying  this  term  to  the  processes  of 
growth  and  repair  of  the  tissues,  are  much  less  affected  than,  on 
rational  grounds,  would  be  anticipated,  even  when  the  lesions  of 
the  valves  have  led  to  enlargement  of  the  heart  and  much  disturb- 
ance of  the  circulation.  Patients  sufferino^  from  the  distressing 
effects  of  cardiac  disease,  viz.,  dyspnoea,  palpitation,  oedema,  etc., 
often  do  not  emaciate.  When  these  effects  occur  in  early  life,  the 
development  of  the  body  is  sometimes  not  remarkably  impaired. 
Even  at  an  advanced  stage,  considerable  embonpoint  is  frequently 
maintained.  It  is  not  uncommon  to  find  the  evidences  of  lesions, 
which  must  have  existed  for  a  long  time,  in  persons  whose  general 
aspect  denotes  excellent  health.  So  far  from  diminished  nutrition 
being  one  of  the  pathological  effects  of  valvular  lesions,  they  are 
rather  to  be  characterized  by  the  absence  of  notable  deterioration 
in  this  respect.  In  cases  in  which  the  origin  of  valvular  lesions 
dates  in  early  life,  and  enlargement  of  the  heart  takes  place  before 
puberty,  the  body  may  attain  to  a  full  development. 


172       LESIOXS    AFFECTING    THE    VALVES    OF    THE    HEART. 


Symptoms  and  Pathological  Effects  referable  to  the  Genito- 
urinary System. 

The  renal  or  emulgent  veins  terminating  in  the  vena  cava  de- 
scendens,  the  kidneys  must  participate  in  the  congestion  of  the 
systemic  venous  system  arising  from  an  impediment  at  the  right 
side  of  the  heart.  These  organs  are  affected  more  directly  than  the 
abdominal  viscera  which  are  tributary  to  the  portal  vein.  So  soon 
as  valvular  lesions  have  led  to  the  anatomical  conditions  involving 
an  obstruction  extending  to  the  yense  cavse  and  their  branches, 
renal  engorgement  necessarily  ensues.  Congestion  of  these  organs 
is  generally  observed  in  examinations  after  death  in  cases  of  val- 
vular disease  accompanied  by  dilatation  of  the  cavities  of  the  right 
side  of  the  heart.  Venous  congestion,  under  these  circumstances, 
does  not  uniformly  occasion  a  greater  flow  of  urine  than  in  health. 
Indeed,  the  quantity  of  urine  is  oftener  diminished  than  increased, 
a  fact  going  to  show  that  diuresis  depends  on  the  amount  of  blood 
conveyed  to  tbe  kidneys  by  the  arteries,  or  on  conditions  pertain- 
ing to  the  blood  itself,  rather  than  on  accumulation  in  the  renal 
veins.  The  urine  is  frequently  scanty,  even  when  the  venous 
obstruction  is  sufficient  to  give  rise  to  general  drops}'-.  The  solid 
constituents  are  relatively  augmented ;  in  other  words,  the  density 
of  the  urine  is  greater  than  in  health.  The  lithatic  deposits  are 
often  abundant.  The  presence  of  albumen  is  not  unfrequently 
shown  by  the  appropriate  tests.  If  the  kidneys  have  not  under- 
gone structural  change,  the  quantity  of  albumen  is  usually  slight. 
It  may  be  found,  on  repeated  examinations  in  the  same  case,  some- 
times present,  and  at  other  times  absent.  The  quantity  at  different 
times  may  be  found  to  fluctuate.  The  presence  of  this  constituent 
in  these  cases  may  be  fairly  attributed  to  the  mechanical  pressure 
incident  to  venous  congestion.  It  does  not  constitute  evidence  of 
structural  change  of  kidney  or  Bright's  disease  when  it  is  in  small 
quantity,  transient. in  duration,  and  notably  fluctuating. 

The  degenerations  of  structure  included  under  the  name  of 
Bright's  disease  are  sometimes  associated  with  valvular  lesions  of 
the  heart.  The  frequency  of  this  combination,  however,  is  less 
than  is  generally  supposed.  Accepting,  on  the  one  hand,  as  evi- 
dence of  coexisting  Bright's  disease  an  abundant  quantit}'  of  albu- 
men constantly  present  in  the  urine  during  life,  or  well-marked 
anatomical  characters  observed  after  death,  and,  on  the  other  hand, 


bright's  disease.  173 

including  cases  only  of  cardiac  disease  which  involve  obstruction 
or  regurgitation,  or  both,  the  two  affections  are  rarely  united.  It 
may  fairly  be  doubted  whether  they  are  associated  sufficiently  often 
to  establish  any  direct  pathological  connection  between  them.  As- 
suming the  existence  of  such  a  connection,  some  have  attributed 
the  renal  affection  to  the  cardiac  disease,  and  others  have  thought 
that  the  valvular  lesions  were  due  to  the  condition  of  the  kidneys. 
They  who  accept  the  first  of  these  suppositions  refer  the  develop- 
ment of  structural  change  in  the  kidneys  to  the  congested  state  of 
these  organs.  But  it  is  by  no  means  settled  that  mere  congestion 
is  adequate  to  produce  this  result.  The  second  supposition  is  more 
tenable.  Pericarditis  and  other  serous  inflammations  are  not  un- 
frequently  developed  in  the  course  of  Bright's  disease ;  and  it  may 
be  reasonably  argued  that  endocarditis  is  occasionally  incidental  to 
the  latter.  Clinical  observation  has  not,  as  yet,  confirmed  the 
correctness  of  this  analogical  argument. 

The  coexistence  of  structural  degeneration  of  the  kidney  is 
shown,  as  already  intimated,  by  the  degree  and  constancy  of  the 
albuminuria,  and  by  the  different  varieties  of  casts  of  the  urinife- 
rous  tubes,  distinctive  of  the  different  kinds  of  degeneration,  which 
the  sediment  of  the  urine  is  found  to  contain  when  subjected  to 
microscopical  examination.'  The  tendency  to  general  dropsy  is 
augmented  by  this  complication ;  renal  and  cardiac  dropsy  are,  in 
fact,  combined.  It  is  needless  to  say  that  the  danger  is  vastly 
increased  by  the  addition  of  so  serious  an  affection  as  structural 
degeneration  of  the  kidneys,  which  exposes  the  patient  to  other 
accidents  than  those  incident  to  the  cardiac  disease,  and  aggravates 
some  of  the  most  important  of  the  pathological  effects  of  the  latter. 

As  regards  the  generative  functions,  the  histories  of  valvular 
affections  which  I  have  collected  furnish  no  facts  of  significance  or 
importance.  I  have  observed,  in  cases  in  which  lesions  had  existed 
for  a  considerable  period  before  puberty,  that  the  genital  organs, 
including,  in  females,  the  mammary  gland,  have  attained  to  a  full 
development. 

•  Vide  Diseases  of  the  Kidney,  etc.,  by  George  Johnson,  M.  D.,  etc.   Lond.,  1852. 


174:      LESIOXS    AFFECTIXG    THE    VALVES    OF    THE    HEART. 


Symptoms  and  Pathological  Effects  referable  to  the  Countenance 
AND  External  Appearance  of  the  Body. 

The  characters  pertaining  to  the  countenance  have,  for  the  most 
part,  been  already  incidentally  mentioned.  Lividity  of  the  prolabia, 
face,  and,  to  some  extent,  apparent  over  the  whole  surface  of  the 
body,  denotes  either  venous  congestion  or  imperfect  oxygenation  of 
the  blood.  The  latter  is  incident  to  the  pathological  effects  taking 
place  in  the  lungs;  the  former,  to  obstruction  at  the  right  side  of 
the  heart.  But  both  conditions  may  be  conjoined.  Cyanosis  de- 
pendent on  congenital  malformations  will  be  considered  hereafter. 
A  dusky  hue  of  the  face,  combined  with  cedema,  is  quite  distinctive 
of  cardiac,  as  contrasted  with  renal,  dropsy.  The  experienced 
clinical  observer  is  able  to  make  this  differential  diagnosis  with 
much  precision  at  a  glance.  When  the  lividity  is  marked,  and  the 
oedema  considerable,  the  face  presents  an  appearance  like  that  of  a 
cadaver  after  strangulation.  The  expression  is  sometimes  so  much 
altered  that  the  person  is  scarcely  recognized  by  familiar  friends. 
Urgent  dyspnoea  induces  an  expression  of  great  anxiety,  distress, 
and  apprehension.  The  painful  spectacle  presented  by  a  case  of 
extreme  suffering  from  so-called  cardiac  asthma  is  thus  vividly 
portrayed  by  Dr.  Hope :  "  Incapable  of  lying  down,  he  is  seen  for 
weeks,  and  even  for  months  together,  either  reclining  in  the  serai- 
erect  posture  supported  by  pillows,  or  sitting  with  the  trunk  bent 
forward  and  the  elbows  or  forearms  resting  on  the  drawn-up  knees. 
The  latter  position  he  assumes  when  attacked  by  a  paroxysm  of 
dyspnoea;  sometimes,  however,  extending  the  arms  against  the 
bed  on  either  side,  to  afford  a  firmer  fulcrum  for  the  muscles  of 
respiration.  With  eyes  widely  expanded  and  starting,  e3'ebrows 
raised,  nostrils  dilated,  a  ghastly  and  haggard  countenance,  and  the 
head  thrown  back  at  every  inspiration,  he  casts  around  a  hurried, 
distracted  look  of  horror,  of  anguish,  and  of  supplication  :  now 
imploring  in  plaintive  moans,  or  quick,  broken  accents,  and  half- 
stifled  voice,  the  assistance  already  often  lavished  in  vain ;  now 
upbraiding  the  impotency  of  medicine ;  and  now,  in  an  agony  of 
despair,  drooping  his  head  on  his  chest,  and  muttering  a  fervent 
invocation  for  death  to  put  a  period  to  his  sufferings.  For  a  few 
hours — perhaps  only  for  a  few  moments — he  tastes  an  interval  of 
delicious  respite,  which  cheers  him  with  the  hope  that  the  worst  is 
over,  and  that  his  recovery  is  at  hand.     Soon  that  hope  vanishes. 


COMPLEXION   AND    CAPILLARY    CONGESTION.  175 

From  a  slumber  fraught  with  the  horrors  of  a  hideous  dream  he 
starts  up  with  a  wild  exclamation  that  'it  is  returning.'  At  length, 
after  reiterated  recurrences  of  the  same  attacks,  the  muscles  of 
respiration,  subdued  by  efforts  which  the  instinct  of  self-preserva- 
tion alone  renders  them  capable  of,  participate  in  the  general  ex- 
haustion, and  refuse  to  perform  their  function.  The  patient  gasps, 
sinks,  and  expires."^  Happily,  the  fearful  intensity  of  suffering 
depicted  in  the  foregoing  sketch  characterizes  a  small  proportion 
only  of  the  cases  of  valvular  disease  which  proceed  to  a  fatal  ter- 
mination. 

Some  cases  of  valvular  disease  are  characterized  by  pallor  of  the 
complexion.  The  coexistence  of  Bright's  disease  is  likely  to  lead 
to  this  effect.  But  it  is  observed  in  some  instances  when  the  kid- 
neys are  not  affected.  It  then  depends  on  alterations  of  the  blood 
proceeding  from  other  causes.  According  to  MM.  Becquerel  and 
Eodier,  an  ansemic  condition  is  induced,  in  a  certain  proportion  of 
cases,  by  cardiac  disease  uncomplicated  with  an  affection  of  the 
kidneys.^  Analj'sis  of  the  blood  shows  a  notable  deficiency  of 
albumen,  together  with  a  reduction  in  the  relative  proportion  of 
blood-corpuscles  and  fibrin.  This  condition  of  the  blood  is  im- 
portant in  connection  with  therapeutical  measures.  It  will  be  ag- 
gravated by  depletion,  and  to  remove  it  by  appropriate  treatment, 
if  practicable,  should  be  an  important  object  with  the  practitioner. 

The  accumulation  of  blood  in  the  right  chambers  of  the  heart 
induces,  in  addition  to  abnormal  fulness  of  the  superficial  veins,  a 
congestive  state  of  the  capillary  vessels,  causing  the  surface  of  the 
body  to  present  an  appearance  like  that  produced  by  exposure  to 
cold.  The  redness  disappears  on  pressure,  and  returns,  more  or 
less  slowly,  after  the  pressure  is  removed.  The  appearance  is  not 
unlike  that  observed  in  the  typhus  and  typhoid  fevers,  although 
the  rationale  is  by  no  means  the  same.  Erythema  affecting  portions 
of  the  surface  occurs  in  some  cases,  not  associated  with  oedema. 
The  lower  extremities  are  most  apt  to  be  affected,  I  have  met 
Avith  an  instance  in  which  the  extremities  of  the  fingers  and  a  por- 
tion of  the  palms  presented  permanently  an  erythematic  redness. 
On  the  other  hand,  in  a  patient  with  considerable  mitral  regurgi- 
tation, the  fingers  at  times  are  bloodless,  being  as  pallid  and  cold  as 
those  of  a  corpse. 

'  On  Diseases  of  the  Heart,  Am.  ed.,  p.  382. 

2  Gazette  Medicale  de  Paris  (13  Avril,  1850).  Vide  Precis  theorique  et  pratiqiae, 
par  C.  Forget. 


CHAPTER   IV. 

PHYSICAL   SIGXS,   DIAGNOSIS,  AND  TREATMENT 
OF   YALYULAR   LESIOXS. 

Endocardial  or  valvular  murmurs — Distinction  between  endocardial  and  exocardial  mur- 
murs— Vascular  murmurs — Distinction  between  inorganic  and  organic  murmurs — Soft 
and  rough  murmurs — Musical  murmurs — Enumeration  of  abnormal  conditions  giving 
rise  to  endocardial  murmurs,  organic  and  inorganic — Valvular  lesions  involving  ob- 
struction or  regurgitation,  or  both,  generally  accompanied  by  a  murmur — Cir,  amstanees 
enabling  the  auscultator  to  determine  whether  lesions  involve  obstruction,  or  regurgi- 
tation, or  both — Mitral  direct,  or  systolic  murmur — Mitral  regurgitant,  or  diastolic 
murmur — Aortic  direct,  or  systolic  murmur — Aortic  regurgitant,  or  diastolic  murmur — 
Localization  of  systolic  murmurs — Localization  of  diastolic  murmurs — Recapitulation  of 
points  involved  in  the  localization  of  systolic  and  diastolic  murmurs — Pathological 
import  of  organic  endocardial  murmurs — Inorganic  murmurs — Abnormal  modifications 
of  the  heart-sounds  in  cases  of  valvular  lesions. — Purring  tremor — Diagnostic  characters 
of  mitral,  aortic,  tricuspid,  and  pulmonic  lesions — Treatment  of  valvular  lesions. 

The  physical  signs  of  lesions  affecting  the  valves  and  orifices  of 
tlie  heart  are  to  be  considered  preparatory  to  entering  on  the  con- 
sideration of  the  diagnosis  of  these  lesions.  It  is  chiefly  by  means 
of  physical  signs  that  the  existence  and  seat  of  valvular  lesions  are 
determined  during  life.  The  symptoms  and  pathological  effects 
which  were  considered  in  the  last  chapter,  afford  importanit  aid  to 
the  diagnostician,  but,  alone,  they  often  fjiil  in  furnishing  positive 
evidence  that  the  valves  or  orifices  are  affected,  and  still  less  do 
they  indicate  the  particular  situation  of  existing  lesions.  To  the 
study  of  the  physical  signs,  in  fact,  in  connection  with  researches 
on  the  mechanism  of  the  heart's  action,  practical  medicine  is  in- 
debted for  the  great  perfection  to  which  the  diagnosis  of  cardiac 
affections  has  attained  within  the  past  few  years.  Here,  as  in  other 
instances,  physical  phenomena  have  a  negative  as  well  as  positive 
application  in  diagnosis ;  that  is  to  say,  while  they  constitute  evi- 
dence of  the  presence  of  certain  lesions,  their  absence  is,  in  general, 
proof  that  lesions  do  not  exist. 

The  diagnostic  signs  of  valvular  lesions  are,  for  the  most  part, 
obtained  by  auscultation.     They  may  be  arranged  into  two  classes. 


ENDOCARDIAL    MURMURS.  177 

viz:  Jirst^  certain  new  or  adventitious  sounds  called  murmurs;  and, 
second,  abnormal  modifications  of  the  natural  cardiac  sounds.  The 
first  class,  or  murmurs,  from  their  practical  importance,  require  to 
be  considered  at  some  length. 


ENDOCARDIAL    OR   VALVULAR   MURMURS. 


All  adventitious  sounds  dependent  on  the  movements  of  the 
heart,  either  replacing  or  superadded  to  the  normal  heart-sounds, 
are  distinguished  as  cardiac  murmurs.  Strictly  speaking,  these 
murmurs  are  heart-sounds,  but,  for  the  sake  of  distinction,  the  latter 
term  is'3onventionally  restricted  to  the  normal  sounds  of  the  heart 
and  their  abnormal  modifications.  The  French  word  hruit  is  often 
used  by  English  and  American  writers.  This  term  with  French 
writers  is  synonymous  with  murmur.  The  latter  term,  first  pro- 
posed by  Dr.  Forbes,  of  London,  is  sufficiently  distinctive  and  con- 
venient, so  that  it  is  quite  needless,  in  this  instance,  to  have  recourse 
to  a  foreign  tongue. 

Cardiac  murmurs  originate  either  within  the  heart  and  blood- 
vessels, or  on  the  peripheral  surface^  of  the  organ.  Dr.  Latham  has 
proposed  to  distinguish  those  produced  within  the  heart  as  endo- 
cardial, and  those  produced  upon  the  surface  as  eococardial  murmurs. 
These  names  are  sufficiently  distinctive.  It  is,  however,  convenient 
to  include  among  endocardial  murmurs  those  produced  in  the  aorta 
and  pulmonary  artery  in  close  proximity  to  the  heart.  Murmurs 
produced  within  vessels  more  or  less  removed  from  the  heart,  ma}* 
be  called  vascular  murmurs.  These  may  originate  either  within  the 
arteries  or  veins.  The  endocardial  and  vascular  murmurs  require 
for  their  production  the  passage  of  currents  of  blood  through  the 
cavities  of  the  heart,  its  orifices  or  the  bloodvessels.  These  murmurs 
are  generally  called  bellows  murmurs  (bruit  de  souffiet)  from  the  re- 
semblance of  the  sound  to  that  produced  by  the  expulsion  of  air 
from  the  nozzle  of  an  ordinary  bellows.  This  resemblance  is  often 
striking,  and  holds  good  in  most  instances  ;  but  some  intra-cardiac 
and  vascular  murmurs  are  very  inappropriately  called  bellows- 
murmurs,  resembling  other  sounds  more  than  that  implied  by  this 
name.  It  is,  however,  to  be  borne  in  mind  that  all  adventitious 
sounds  produced  within  the  heart  and  vascular  sj^stem,  are  conven- 
12 


178  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

tionally  known  as  bellows  murmurs.  This  name  was  applied  to 
them  by  the  illustrious  discoverer  of  auscultation,  Laennec,  by 
whom  they  were  first  described. 

Exocardial  murmurs  are  occasioned  by  the  rubbing  together  of 
the  visceral  and  parietal  surfaces  of  the  pericardium,  and  some- 
times by  the  heart  impinging  against  the  neighboring  parts  exterior 
to  the  pericardium.  These  murmurs  are  usually  called,  from  the 
manner  of  their  production,  aitrition  or  friction  murmurs.  These 
will  be  considered  hereafter  in  connection  with  the  diseases  affecting 
the  pericardium. 

In  treating  of  endocardial  murmurs,  the  practical  points  to  be 
considered  relate  to  the  different  characters  which  they  present,  the 
morbid  conditions  which  they  denote,  their  significance  and  value 
as  signs  of  disease,  and  their  application  to  the  diagnosis  of  val- 
vular affections.  These  murmurs  may  be  produced  within  the 
cavities  of  the  heart,  at  the  auriculo-ventricular  or  the  ventriculo- 
arterial  orifices,  and  within  the  aorta  or  pulmonary  artery  near  the 
junction  of  these  vessels  with  the. ventricles.  Strictly  speaking, 
murmurs  produced  in  the  last-named  situations  are  not  endocardial, 
but  it  is  most  convenient  to  include  them  in  the  same  class.  It  is 
practicable  often,  if  not  generally,  to  determine  by  means  of  phy- 
sical exploration,  in  which  one  of  the  cavities,  orifices,  or  vessels 
mentioned,  originate  the  murmurs  heard  in  individual  cases.  The 
importance  of  this  localization,  as  pointing  to  the  seat  of  the  lesions 
which  occasion  the  murmurs,  is  obvious.  The  special  objects  to 
which  the  study  of  this  class  of  murmurs  has  been  subservient, 
may  be  stated  as  follows :  To  determine  the  existence  or  non-exist- 
ence of  valvular  disease ;  to  determine  the  particular  situation  of 
structural  lesions  ;  to  determine  the  character  of  lesions  and  certain 
of  their  effects,  especially  on  the  blood-currents  through  the  diiferent 
orifices. 

Endocardial  murmurs  are  not  always  due  to  lesions  of  structure 
or  organic  disease.  They  occur  as  a  result  of  certain  blood-changes 
and  of  functional  disorder  of  the  heart.  The  latter  are  distinguished 
as  inorganic  murmurs,  while  those  dependent  on  structural  changes 
are  called  organic  murmurs.  It  is  of  great  importance  to  discrimi- 
nate, in  practice,  between  organic  and  inorganic  murmurs.  With 
proper  knowledge  and  care  this  can  generally  be  done.  The  points 
involved  in  the  discrimination  are  to  be  considered,  I  shall,  how- 
ever, first  consider  murmurs  which  it  is  assumed  are  organic,  and 
afterwardspointout  the  means  of  making  the  distinction  in  practice. 


ORGANIC    ENDOCARDIAL    MURMURS.  179 

Inorganic  murmurs  will  claim  consideration  also  in  connection 
with  functional  disorders  of  the  heart.  It  is  then  to  be  understood 
that,  for  the  present,  reference  is  had  to  organic  murmurs. 

Organic  murmurs,  as  regards  their  sensible  characters,  differ  in 
a  marked  degree  in  different  cases.  In  the  majority  of  cases  they 
resemble  a  bellows  sound.  Murmurs  of  this  description  are  said 
to  be  soft  mxirmurs.  They  vary  greatly  in  intensity,  pitch  and 
duration.  In  some  instances  they  are  so  feeble  as  to  be  just  appre- 
ciable; in  other  instances  they  are  so  loud  as  to  be  heard  over  the 
whole  chest,  and  are  sometimes  perceived  by  the  patient,  especially 
in  the  night  time.  In  several  cases  that  have  come  under  my 
observation,  patients  have  accurately  described  the  sound,  which 
had  attracted  their  attention  before  any  exploration  of  the  chest  had 
been  made.  It  is  sometimes  heard  by  others  at  a  distance  from  the 
chest.  I  have  known  instances  where  this  has  occurred  to  persons 
occupying  the  same  bed  with  patients  affected  with  disease  of  the 
heart.  It  may  not  be  amiss  to  mention,  in  this  connection,  that  physi- 
cians and  medical  students  not  unfrequently  imagine  they  discover, 
during  the  night,  a  caixliac  bellows  murmur  in  their  own  persons, 
mistaking  for  it  a  sound  produced  by  the  movement  of  the  head  on 
the  pillow  synchronously  with  the  ventricular  systole,  or,  possibly, 
by  the  current  of  blood  in  the  cerebral  arteries.  Between  the 
extremes  of  feebleness  and  loudness,  different  cases  present  every 
degree  of  gradation  as  respects  intensity.  The  pitch  varies  within 
certain  limits.  Bouillaud  first  proposed  the  plan  of  representing 
the  pitch  of  bellows  murmurs  by  whispered  words  and  letters, 
which  is  much  more  convenient  and  clear  than  verbal  descriptions. 
The  highest  pitch,  unless  the  sound  become  musical,  may  be  repre- 
sented by  the  letter  S,  and  a  lower  grade,  but  still  acute,  by  the 
letter  K.  When  the  pitch  is  low  it  is  often  represented  by  the  word 
WHO,  and  when  still  more  grave  by  the  word  awe.  These  letters 
and  words  were  selected  for  this  purpose  by  Dr.  Hope.  The  pitch 
of  the  murmur  is  a  point  of  some  importance,  but  it  has  far  less 
significance  than  was  supposed  by  the  distinguished  author  just 
named,  whose  labors  contributed  largely  to  our  present  knowledge 
of  the  diagnosis  of  diseases  of  the  heart.  The  duration  of  bellows 
murmurs  is  by  no  means  uniform  in  different  cases.  It  is  some- 
times extremely  brief,  resembling  the  shortest  possible  puff,  and  in 
other  cases  prolonged  over  half,  three-quarters  and  even  a  larger 
proportion  of  the  heart's  beat  or  revolution. 

Murmurs  which  lack  the  softness  of  those  just  referred  to,  and 


180  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS, 

which  bear  but  a  remote  resemblance,  or  none  whatever,  to  a  bel- 
lows sound,  are  distinguished  as  harsh  or  rough  murmurs.  They 
are  always  organic;  in  other  words,  they  invariably  denote  struc- 
tural lesions  of  some  kind.  These  also  differ  greatly  in  their  sen- 
sible characters.  Different  varieties  have  been  described  and 
named  from  their  resemblance  to  certain  sounds.  Thus,  French 
writers  recognize  filing,  grating^  and  rasping  murmurs  {hruit  de  lime, 
hruit  de  rape,  hruit  de  scie,  etc.),  comparing  the  sounds  to  those  pro- 
duced by  filing  and  rasping  wood.  In  a  case  which  recently  came 
under  my  observation,  the  sound  was  precisely  like  the  croaking 
of  a  frog.'  The  rough  murmurs,  in  fact,  in  different  cases  suggest 
various  comparisons.  The  varieties,  however,  are  of  very  little 
prajctical  consequence.  They  have  not,  severally,  any  special  sig- 
nificance. The  rationale  of  the  diversity  is  not  well  understood. 
It  suffices  to  consider  them  simply  as  presenting  different  modifica- 
tions and  degrees  of  roughness,  the  latter  being  the  only  distinctive 
feature  worthy  of  being  noted.  The  distinction,  indeed,  between 
roughness  and  softness  is  not  of  much  importance  in  a  practical 
point  of  view,  beyond  the  fact  that  the  former  denotes,  intrinsicallj', 
structural  lesions.  The  absence  of  roughness,  however,  is  by  no 
means  evidence  that  structural  lesions  do  not  exist.  It  is  stated 
by  some  writers  that  a  rough  murmur  indicates  something  more 
than  the  existence  of  structural  lesions,  viz :  the  presence  of  cal- 
careous deposit  on  the  valves,  orifices,  or  lining  membrane  of  the 
heart-cavities  or  vessels.  This  statement  is  not  correct.  I  have 
met  with  cases  in  which  the  murmur  was  notably  rough  and  no 
calcareous  deposit  was  found  after  death.  On  the  other  hand,  in 
cases  in  which  the  deposit  is  abundant,  the  murmur  is  frequently 
devoid  of  roughness.  Rough  murmurs,  as  a  rule,  are  more  intense 
than  soft  murmurs.  They  are  oftener  perceived  by  the  patient. 
In  a  case  in  which  the  murmur  resembled  the  croaking  of  a  frog, 
the  sound  was  accurately  described  by  the  patient,  and  was  dis- 
tinctly heard  when  the  ear  was  in  close  proximity  to  the  chest,  but 
not  in  actual  contact.  The  duration  of  rough  as  of  soft  murmurs 
varies  considerably  in  different  cases,  but  they  are  rarely,  if  ever, 
so  brief  as  the  latter  in  the  instances  in  which  a  short  puft'  only  is 
heard.  A  soft  murmur  in  some  cases  during  the  progress  of  dis- 
ease is  converted  into  a  rough  murmur ;  and  the  converse  of  this 

'  Following  tlie  custom  of  some  Freucli  writers  of  considering  a  peculiar  sound 
as  a  variety  of  murmur  and  giving  it  a  name,  this  should  be  called  bruit  de  gren- 
ouille  ! 


OEGANIC    ENDOCARDIAL    MURMURS.  181 

also  occurs.  A  raiinnur  may  be  soft  when  the  action  of  the  heart 
is  feeble  or  moderately  strong,  and  become  rough  when  the  organ 
is  excited  into  greater  activity ;  and,  conversely,  it  is  possible  that 
a  murmur  which  is  soft  when  the  heart  acts  with  violence,  may  be- 
come rough  when  the  organ  is  more  tranquil. 

Murmurs  sometimes  have  a  musical  intonation.  The  sounds  are 
compared  to  the  sibilant  rale,  the  cooing  of  a  dove,  the  whining  of 
a  puppy,  etc.  {bruit  de  sifflement,  bruit  sibilant,  bruit  de  roucoulement, 
de  inaulemenl,  etc.).  These  are  as  much  less  frequent  than  the 
rough  murmurs  as  the  latter  are  more  infrequent  than  soft  mur- 
murs. They  are  interesting  only  as  clinical  curiosities.  They 
have  no  special  pathological  or  diagnostic  significance,  except  that 
they  denote  the  existence  of  organic  disease.  They  are  preceded 
by,  and  may  give  place  to,  the  common  bellows  murmur.  They 
may  alternate  wjth  the  latter  in  diilerent  conditions  of  the  heart's 
action.  As  remarked  by  Bouillaud  and  Hope,  it  is  as  intelligible 
that  a  bellows  murmur  may  be  transformed  into  a  musical  tone  as 
that  a  change  in  the  disposition  of  the  lips  changes  a  blowing  into 
a  whistling  sound. 

This  will  suffice  for  a  general  description  of  endocardial  or 
valvular  organic  murmurs.  Their  relations  to  the  two  sounds  of 
the  heart  and  to  the  different  currents  of  blood,  the  different  situa- 
tions to  which  they  may  be  limited,  or  in  which  they  are  heard 
with  their  maximum  intensity,  and  the  directions  in  which  they 
are  transmitted,  are  of  flir  greater  importance,  as  regards  diagnosis, 
than  their  intrinsic  characters.  To  these  practical  points  attention 
will  now  be  directed. 

The  passage  of  the  blood  through  the  cavities  and  orifices  of  the 
heart  and  the  large  vessels,  in  health,  takes  place  noiselessl}'-, 
excepting  the  normal  heart-sounds  which  have  been  considered.' 
The  bulk  of  the  heart,  the  capacity  of  its  cavities,  the  smoothness 
of  the  endocardium,  the  size  of  the  orifices  and  vessels,  the  protec- 
tion afforded  by  the  valves  against  regurgitating  currents,  and  the 
quality  of  the  blood,  are  all  so  nicely  harmonized  that  the  circula- 
tion is  unattended  by  a  murmur  unless  abnormal  conditions  of 
some  kind  exist.  The  morbid  changes  which  may  give  rise  to 
adventitious  sounds  are  various.  The  presence  of  a  murmur  in- 
volves only  the  fact  that  there  is  something  abnormal.  It  does  not 
indicate  the  seat  or  nature  of  the  change  that  has  taken  place,  until 
certain  contingent  circumstances  are  taken  into  account.     Of  the 

'  Chap.  I.,  page  58  e<  seq. 


182  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

abnormal  conditions  whicli  clinical  observation  has  shown  to  be 
productive  of  murmurs,  the  more  important  are  the  following: 
Roughness  of  the  endocardium  and  of  the  membrane  lining  the 
aorta  or  pulmonary  artery ;  the  presence  of  deposits  (exudations 
and  coagula)  which  interrupt  or  disturb  the  current  of  blood,  and 
the  projection  into  the  current  of  rigid,  unyielding  valves;  contrac- 
tion of  the  auriculo-ventricular  or  the  ventriculo-arterial  orifices; 
dilatation  and  contraction  of  the  large  vessels  connected  with  the 
heart ;  insufficiency  of  the  valves  designed  to  protect  the  orifices 
just  named,  due  either  to  lesions  affecting  the  valves  or  to  dilata- 
tion of  the  orifices ;  aneurismal  dilatation  of  a  portion  of  one  of  the 
ventricles;  dilatation  of  the  whole  ventricle,  rendering  the  size  of 
the  cavity  disproportionate  to  the  quantity  of  blood ;  the  formation 
of  clots  in  the  ventricles ;  certain  alterations  in  the  composition  of 
the  blood;  sudden  diminution  in  the  circulating, mass  of  blood; 
functional  disorder  of  the  action  of  the  heart ;  communication 
between  the  two  ventricles,  and  other  congenital  malformations. 
In  this  list  of  abnormal  conditions,  the  alteration  in  the  composi- 
tion of  the  blood,  sudden  diminution  in  the  circulating  mass,  and 
functional  disorder  of  the  heart,  are  to  be  distinguished  as  inorganic, 
that  is,  structural  lesions  of  the  heart  are  not  involved.  Murmurs 
due  to  these  conditions  are  therefore  inorganic  murmurs.  Murmurs 
dependent  on  any  of  the  other  conditions  enumerated  are  organic 
murmurs. 

The  physical  conditions  on  which,  in  the  vast  majority  of  cases, 
murmurs  are  dependent,  are  classed  under  the  head  of  valvular 
lesions,  which  were  described  in  the  preceding  chapter.  Under 
this  head  are  embraced  the  greater  part  of  the  conditions  just 
enumerated.  The  morbid  appearances  which  the  valves  and 
orifices  present  in  different  cases,  it  has  been  seen,  are  extremely 
diversified,  consisting  of  various  forms  and  degrees  of  roughness 
from  calcareous  deposits;  vegetations  of  greater  or  less  size,  and 
more  or  less  numerous,  and  variously  disposed ;  thickening,  on  the 
one  hand,  and  attenuation,  rupture,  perforations,  and  a  cribriform 
condition,  on  the  other  hand ;  crumpling  and  contraction  to  a 
greater  or  less  extent ;  cartilaginous  stiffness  and  ossific  rigidity ; 
disruption  of  tendinous  cords  and  fleshy  columns;  adhesion  of  the 
valves  to  each  other  and  to  the  inner  surface  of  the  heart  or 
vessels;  congenital  deficiency  or  deformity,  etc.  These  changes,  it 
has  also  been  seen,  are  important  or  serious  in  proportion  as  they 
my olve,  fir sthj,  contraction  of  one  or  more  of  the  orifices  and  con- 


ORGAXIC    EXDOCAEDIAL    MURMURS.  183 

sequent  obstruction  to  the  free  passage  of  blood;  secondly^  insuffi- 
ciency of  the  valves  or  patency  of  one  or  more  of  the  orifices, 
and  consequent  regurgitation ;  thirdly^  contraction  and  patency 
combined.  These  immediate  effects  give  rise  to  those  secondary 
and  remote  derangements  of  the  circulation  which  are  observed 
to  result  from  valvular  lesions,  and  eventuate  in  enlargement  of 
the  heart  progressively  increasing  in  proportion  to  the  duration 
and  amount  of  either  obstruction  or  regurgitation,  or  both.  But 
morbid  conditions  included  under  the  head  of  valvular  lesions  may 
exist  which  involve  neither  contraction  nor  insufficiency,  and,  con- 
sequently, do  not  occasion  either  obstruction  or  regurgitation. 
Thickening,  roughening,  vegetations,  etc.,  may  be  present  without 
the  results  just  mentioned,  and  therefore  without  the  ulterior  con- 
sequences in  which  consists  the  importance  or  seriousness  of  valvu- 
lar lesions.  Valvular  lesions  by  no  means  necessarily  involve 
immediate  danger;  they  may  exist  for  a  long  period  and  no  evils 
arise  from  them.  In  a  practical  point  of  view,  this  is  a  fact  of 
great  importance  when  it  is  considered  that  innocuous  lesions  give 
rise  to  endocardial  murmurs.  It  is  to  be  borne  in  mind  that 
valvular  lesions  which  do  not  occasion  any  of  the  evil  consequences 
arising  from  obstruction  or  regurgitation,  nevertheless  may  involve 
physical  conditions  requisite  for  the  production  of  murmurs.  This 
important  point  will  recur  after  the  following  questions  have  been 
considered :  Are  valvular  lesions  which  do  involve  either  obstruc- 
tion or  regurgitation,  or  both,  uniformly  or  generally  accompanied 
by  murmur?  What  are  the  circumstances  which,  considered  in 
connection  with  the  presence  of  a  murmur,  enable  the  auscultator 
to  determine  whether  existing  lesions  involve  either  contraction  or 
insufficiency,  or  both  ?  Can  the  particular  seat  of  valvular  lesions 
be  determined,  and,  if  so,  in  what  manner?  The  practical  import- 
ance of  these  questions  is  sufficiently  obvious.  Before  proceeding 
to  their  consideration,  the  reader  may  be  reminded  of  the  fact  that 
in  the  vast  majority  of  the  cases  of  valvular  lesions  they  are  con- 
fined to  the  left  side  of  the  heart,  affecting  the  aortic  or  mitral 
orifices,  singly  or  combined.  The  questions  just  propounded, 
therefore,  will  relate  mainly  to  the  valves  and  orifices  connected 
with  the  left  ventricle. 


184  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 


ylre  valvular  lesions  ivhich  involve  either  ohslruction  or  regurgitation,  or 
both,  uniformly  or  generally  accompanied  by  murmur  ? 

This  question  may  be  answered  affirmatively  as  regards  the 
general,  but  not  as  regards  the  uniform  occurrence  of  murmur. 
Clinical  experience  shows  that  in  the  vast  majority  of  cases  mur- 
mur coexists ;  and  it  is  probable  that  in  most  of  the  instances  in 
which  at  a  certain  stage  in  the  progress  of  the  disease  careful  phy- 
sical exploration  fails  in  discovering  any  murmur,  it  either  has 
existed  or  becomes  developed  subsequently.  Cases  have  been 
reported  in  which  valvular  lesions  involving  considerable  and  even 
great  obstruction  and  regurgitation,  were  found  after  death,  and  no 
murmur  had  been  discovered  during  life.  Such  cases  are  rare; 
several  are  given  by  Dr.  Stokes.^  The  saptie  author  cites  cases  in 
which  murmurs  had  existed,  but  disappeared  in  the  progress  of  the 
disease,  generally  towards  the  close  of  life.^ 

These  cases  show  that  the  physical  conditions  necessary  for  the 
production  of  a  murmur  are  not  constantly  associated  with  even 
extensive  lesions  of  the  valves  and  orifices;  and  that  when  these 
conditions  are  associated  (which  is  a  rule  with  very  few  exceptions), 
a  murmur  sometimes  disappears  in  consequence  of  diminished 
power  of  the  ventricular  contractions.  Owing  to  the  enfeebled 
action  of  the  heart  which  often  precedes,  for  a  greater  or  less  period, 
a  fatal  termination,  a  murmur  which  has  existed  may  disappear, 
the  blood  not  being  propelled  with  force  sufficient  for  its  continu- 
ance, notwithstanding  the  persistence  of  physical  conditions  suffi- 
cient for  its  production.  The  practical  bearing  of  the  question 
under  consideration  relates  chiefly  to  the  value  of  the  murmui's  in 
a  negative  point  of  view;  in  other  words,  to  the  evidence  afforded 
by  the  absence  of  murmur  against  the  existence  of  valvular  lesions. 
It  follows  from  the  statements  just  made,  that  the  absence  of  mur- 
mur is  not  positive  proof  of  the  non-existence  of  serious  valvular 
lesions.  But  it  follows,  also,  that  the  probability  of  such  lesions 
being  present  when  a  murmur  is  not  discoverable,  is  exceedingly 
small ;  so  small,  indeed,  that  it  may  be  almost  said  to  be  with  safety 
disregarded  in  diagnosis,  especially  if  those  cases  are  excluded  in 

'  Diseases  of  the  Heart  and  Aorta,  Am.  ed.,  p.  157  et  seq. 

2  Dr.  Stokes  refers  to  a  series  of  cases  illustrative  of  the  disappearance  of  mur- 
mur in  progressive  valvular  disease,  collected  by  J.  M.  O'Ferrall,  M.  R.  I.  A.,  and 
published  in  the  Dublin  Journal  of  Medical  Science,  series  1st,  vol.  xxiii.,  1843. 


CLASSIFICATION    OF    OEGANIC    MURMURS.  185 

which  an  exploration  of  the  chest  is  made  when  the  action  of  the 
heart  is  weakened  by  the  failure  of  the  vital  forces,  or  by  any  causes 
depressing  the  muscular  power  of  the  organ.  It  is  a  point  of  great 
importance  to  determine  in  individual  cases  whether  valvular  lesions 
do  or  do  not  exist.  The  presence  of  a  murmur  by  no  means  war- 
rants the  conclusion  that  lesions  do  exist,  as  will  appear  more  fully 
after  inorganic  murmurs  have  been  considered.  The  absence  of 
murmur,  on  the  other  hand,  warrants  the  conclusion  that  lesions 
do  not  exist,  the  probability  of  error  being  exceedingly  small,  pro- 
vided the  heart  be  not  from  any  cause  greatly  weakened. 

What  are  the  circumstances  which,  taken  in  connection  with  a  murmur, 
enable  the  auscultator  to  determine  ivhether  existing  lesions  involve 
either  obstruction  or  regurgitation,  or  both'? 

With  reference  to  this  question,  as  well  as  to  that  which  follows, 
it  is  necessary  to  have  a  clear  idea  of  the  relations  of  endocardial 
murmurs  to  the  two  sounds  of  the  heart,  respectively,  and  to  the 
different  currents  of  blood.  After  the  systolic  contraction  of  the 
ventricles,  the  blood  passes  through  the  auriculo-ventricular  orifices 
from  the  auricles  into  the  ventricles.  Limiting  the  attention  to  the 
left  side  of  the  heart,  this  may  be  designated  the  direct  mitral  current. 
The  systolic  ventricular  contractions  impel  the  blood  from  the 
cavity  of  the  ventricle  into  the  arterial  vessels.  The  current  of 
blood  from  the  cavity  of  the  left  ventricle  into  the  aorta,  may  be 
distinguished  as  the  direct  aortic  current.  These  are  the  normal 
blood-currents.  Others  are  incident  to  disease.  If  the  mitral  valves 
are  insuflficieut,  more  or  less  of  the  blood  contained  in  the  cavity  of 
the  left  ventricle  is  impelled  backwards  into  the  left  auricle.  Here, 
then,  is  a  regurgitant  current  which  does  not  exist  when  the  valves 
are  sound  and  sufficient.  It  may  be  called  a  mitred  regurgitant  cur- 
rent. If  insufficiency  of  the  aortic  valves  occurs  as  an  effect  of 
lesions  in  this  situation,  the  blood  which  remains  in  the  aorta 
after  the  ventricular  systole,  regurgitates  into  the  ventricular  cavity 
to  a  greater  or  less  extent.  This  may  be  distinguished  as  an  aortic 
regurgitant  current.  Now,  each  of  these  four  currents  may  give  rise 
to  a  murmur.  Murmurs  produced  by  these  different  currents  may 
be  named  accordingly.  Hence,  there  may  be  a  mitral  direct  mur- 
mur;  a  mitral  regurgitant  murmur;  an  aortic  direct  murmur^  and  an 
aortic  regurgitant  murmur.    These  several  murmurs  sustain  different 


186  PHYSICAL    SIGNS    OF    VALVULAR    LESIOXS. 

relations  to  the  heart-sounds,  as  will  be  obvious  on  a  little  consider- 
ation. 

A  mitral  direct  murmur  follows  the  diastolic  or  second  sound  of 
the  heart,  and  precedes  the  systolic  or  first  sound ;  in  other  words, 
it  takes  place  during  the  long  silence  or  pause  wbich  separates  the 
diastolic  and  systolic  sounds.  If  we  divide  the  murmurs  into  two 
classes  (which  it  is  convenient  to  do),  viz.,  into  diastolic  and  systolic 
murmurs,  according  to  their  relations  to  one  of  the  two  heart- 
sounds,  a  mitral  direct  murmur  will  be  included  in  the  class  of 
diastolic  murmurs.  In  point  of  fact,  it  occurs  just  before  the  systo- 
lic sound,  and  is,  strictly  speaking,  more  accurately  called  a  pre- 
systolic than  a  diastolic  murmur.  For  convenience,  however,  it 
may  be  distinguished  as  the  mitral  diastolic  murm^ur. 

A  mitral  regurgitant  Tnurmur,  on  the  other  hand,  being  produced 
by  the  ventricular  systole,  accompanies  or  follows  the  systolic 
sound.  It  belongs,  therefore,  in  the  class  of  systolic  murmurs,  and 
may  be  called  the  mitral  systolic  murmur. 

An  aortic  direct  murmur,  also  produced  by  the  ventricular  systole, 
is  a  systolic  murmur ;  it  accompanies  or  follows  the  systolic  sound, 
and  may  be  called  the  aortic  systolic  murmur. 

An  aortic  regurgitant  murmur,  on  the  other  hand,  produced  by 
the  retrograde  current  from  the  aorta  into  the  ventricle  after  the 
systolic  contraction,  either  follows  or  replaces  the  diastolic  sound. 
It  is,  therefore,  a  diastolic  murmur,  and  may  be  called  the  aortic 
diastolic  murmur. 

The  following  recapitulation  shows,  at  a  glance,  the  titles  of  the 
different  murmurs  and  their  relations,  respectively,  to  the  blood- 
currents  and  heart-sounds: — 

Systolic  murmurs,  accompanying,  replacing,  or  closely  succeeding 
the  systolic  or  first  sound  of  the  heart,  consist  of,  1st.  A  miti'al 
regurgitant  or  a  mitral  systolic  murmur;  and,  2d.  An  aortic  direct 
or  an  aortic  systolic  murmur. 

Diastolic  murmurs,  accompanying,  replacing,  closely  preceding  or 
following  the  diastolic  or  second  sound  of  the  heart,  consist  of,  1st. 
A  mitral  direct  or  a  mitral  diastolic  murmur ;  and,  2d.  An  aortic 
regurgitant  or  an  aortic  diastolic  murmur.  Each  of  these  four 
murmurs  claims  distinct  notice  with  reference  to  the  important 
practical  question  under  consideration. 

1.  Mitral  Direct  or  Diastolic  Murmur. — This  occurs  more  unfre- 
quently  than  the  other  three  murmurs.     It  is  rarely  observed,  not 


MITRAL    DIRECT    OR    DIASTOLIC    MURMUR.  187 

because  the  physical  conditions,  so  far  as  lesions  are  concerned,  are 
proportionately  infrequent,  but  in  consequence  of  the  contraction 
of  the  left  auricle  not  taking  place  with  power  sufficient  to  impel 
the  current  of  blood  through  the  auriculo- ventricular  orifice  with 
force  enough  to  give  rise  to  audible  sonorous  vibrations.  Some 
have  disputed  the  possibility  of  this  murmur.  Not  only  does  it 
occur,  but  there  is  reason  to  believe  that  its  occurrence  is  less  rare 
than  is  generally  supposed.  Roughness  of  the  mitral  valve  on  its 
auricular  aspect,  and  especially  irregular  calcareous  deposits,  vege- 
tations, etc.,  projecting  from  this  surface  of  the  valve,  or  from  the 
orifice,  rippling,  as  it  were,  the  current  of  blood  in  its  direct  course 
from  the  auricle  to  the  ventricle,  are  physical  conditions  which  give 
rise  to  this  murmur;  but  they  are  seldom  adequate  unless  contrac- 
tion of  the  mitral  orifice  be  superadded.  If  there  be  sufficient 
obstruction  at  this  orifice,  the  blood  is  thrown  into  sonorous  vibra- 
tions in  consequence  of  the  greater  velocity  of  the  stream,  HNq^er- 
trophy  of  the  muscular  portion  of  the  left  auricle  contributes  to  the 
production  of  the  murmur,  or  renders  it  more  intense,  the  blood 
being  impelled  through  the  contracted  orifice  with  greater  force. 
As  a  rule,  a  mitral  direct  or  diastolic  murmur  denotes  not  only  the 
existence  of  mitral  lesions,  but  mitral  contraction.  This  rule, 
however,  is  not  without  exceptions,  but  they  are  probably  ex- 
tremely rare. 

The  existence  of  contraction  and  consequent  obstruction  is 
further  shown  hj  associated  circumstances.  One  of  these  is  in- 
tensification or  reinforcement  of  the  pulmonary  second  sound  of 
the  heart  in  the  second  left  intercostal  space.  The  significance  of 
this  sign  has  been  alluded  to  in  connection  with  the  subject  of 
hypertrophy  of  the  right  ventricle,^  It  will  be  noticed  presently 
under  the  head  of  abnormal  modifications  of  the  heart-sounds  inci- 
dent to  valvular  lesions.  Symptoms,  in  distinction  from  signs,  are 
also  to  be  taken  into  account.  Those  which,  in  connection  with 
the  presence  of  a  mitral  direct  or  diastolic  murmur,  point  to  mitral 
contraction,  and  which  afford,  measurably,  evidence  of  the  amount 
of  obstruction,  are  phenomena  denoting  congestion  of  the  lungs, 
viz.,  dyspnoea,  defective  oxygenation  of  the  blood,  hasmoptysis,  and 
pulmonary  apoplexy.  The  pathological  relations  of  these  events 
have  been  already  considered.^  The  manner  in  which  this  mur- 
mi]r,  as  also  the  other  murmurs,  may  be  localized  by  auscultation, 

'  Chap.  I.,  page  G5.  2  Vide  Chap.  III. 


188  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

will  be  considered  in  connection  with  the  question  which  follows 
that  under  present  consideration. 

2.  Mitral  Regurgitant  or  Systolic  Murmur. — This  is  as  common  as 
the  preceding  murmur  is  rare.  According  to  ray  own  observations, 
it  is  the  murmur  most  frec[uently  met  with  in  cases  of  organic  dis- 
ease of  the  heart.  Whenever  the  mitral  valve  is  rendered  insuffi- 
cient by  abnormal  changes,  a  portion  of  the  blood  contained  in  the 
left  ventricle  is  driven  backwards  by  the  ventricular  systole  into 
the  left  auricle.  This  regurgitant  current  passes  through  an  orifice 
frequently  contracted  and  generally  more  or  less  irregular,  the 
surfaces  roughened  by  calcareous  deposit,  warty  excrescences,  etc. 
The  physical  conditions  pertaining  to  the  lesions  are  the  same  as  in 
the  cases  in  which  a  mitral  direct  or  diastolic  murmur  is  produced, 
with  this  important  difference,  viz.,  in  the  latter  instance  the  force 
of  the  current  is  comparatively  feeble,  being  due  to  the  contractile 
movement  of  the  left  auricle,  while  in  the  former  instance  the  blood 
is  propelled  with  a  momentum  commensurate  with  the  power  of 
the  left  ventricle.  The  force  of  the  regurgitant  current,  in  fact,  is 
such  that  a  murmur  is  almost  invariably  produced ;  the  exceptions 
are  so  few  that,  practically,  the  fact  of  their  occurrence  may  be 
almost  disregarded.  Insufficiency  of  the  mitral  valve,  then,  is 
accompanied  by  a  mitral  regurgitant  murmur  in  the  vast  majority 
of  cases.  Is  it  true,  on  the  other  hand,  that  a  systolic  murmur 
referable  to  the  mitral  orifice  as  uniformly  denotes  the  existence  of 
insufficiency  or  regurgitation  ?  This  question  must  be  answered 
in  the  negative.  There  are  rules,  to  be  presently  considered,  which 
enable  the  auscultator  to  localize  a  systolic  murmur  at  the  mitral 
orifice.  Now,  of  the  instances  in  practice  in  which  a  murmur  is 
referred  to  this  situation,  in  only  a  certain  proportion  does  regurgi- 
tation occur;  in  other  words,  a  murmur  may  be  produced  at  or 
near  the  mitral  orifice,  due  to  roughness,  calcareous  deposit,  etc., 
without  the  valve  being  thereby  rendered  insufficient.  It  is  im- 
portant that  this  fact  should  be  borne  in  mind.  The  gravity  of 
valvular  lesions,  as  has  been  seen,  depends  on  the  amount  of 
obstruction  and  regurgitation  resulting  from  them ;  hence,  the 
importance  of  bearing  in  mind  that  a  mitral  sj^stolic  murmur  is 
not  always,  strictly  speaking,  a  regurgitant  murmur,  ^.  e,,  the  mur- 
mur may  be  produced  without  regurgitation.  AVhat,  then,  are  the 
circumstances  connected  with  the  murmur  which  denote  insuffi- 
ciency or   regurgitation?     The   diffusion   of  the   murmur   is   an 


MITRAL    EEGURGITAXT    OR    SYSTOLIC    MURMUR.         189 

important  point  with  reference  to  this  question.  If  the  murmur  be 
diffused  over  the  left  side,  extending  to  the  lateral  surface  of  the 
chest,  and,  as  is  not  unfrequentlj  the  case,  even  to  the  posterior 
surface,  regurgitation  may  be  assumed.  This  diffusion  is  more 
valuable  in  a  positive  than  in  a  negative  point  of  view;  that  is  to 
say,  regurgitation  may  exist  without  diffusion  of  the  murmur, 
while  the  converse,  as  a  rule,  does  not  hold  good.  Other  associated 
circumstances  pointing  to  regurgitation  are  the  symptoms  and 
pathological  events  proceeding  from  pulmonary  congestion,  which 
have  been  considered  in  the  preceding  chapter.  Considerable 
regurgitation,  however,  may  continue  for  a  long  time  before  these 
become  developed.  Clinical  observation  shows  that  mitral  regur- 
gitation is  long  borne  without  serious  inconvenience,  especially  if 
mitral  contraction  does  not  coexist.  Symptoms,  therefore,  do  not 
afford  much  aid  in  an  early  diagnosis  of  mitral  insufficiency.  A 
comparison  of  the  aortic  and  the  pulmonary  second  sound  has  an 
important  bearing  on  the  question  just  stated.  Greater  relative 
intensity  of  the  pulmonic  second  sound  is  a  sign  of  marked  signifi- 
cance in  this  connection.  It  has  a  twofold  significance.  The 
intensitj^  of  the  aortic  second  sound  is  diminished  in  proportion  to 
the  amount  of  blood  which  regurgitates  through  the  mitral  orifice, 
the  stream  which  should  pass  into  the  aorta  with  each  ventricular 
systole  being  lessened.  The  abnormal  feebleness  of  the  aortic 
second  sound  is  thus  proportionate  to  the  degree  of  mitral  insuffi- 
ciency. In  this  point  of  view,  the  greater  relative  intensity  of  the 
pulmonic  second  sound  is  significant.  But  the  intensity  of  this 
sound  becomes  positively  augmented.  When  this  is  the  case,  it 
shows  that  the  regurgitation  has  been  sufficient  to  induce  a  degree 
of  obstruction  to  the  pulmonary  circulation  which  has  induced 
h3q:iertrophy  of  the  right  ventricle  in  the  manner  already  described. 
Attention  to  the  diffusion  of  the  murmur,  and  a  comparison  of  the 
aortic  and  pulmonic  second  sound,  enable  the  auscultator  generally 
to  determine  with  much  positiveness  whether  a  mitral  sj^stolic 
murmur  denotes  insufficiency,  and  also  to  form  an  idea  of  the 
amount  of  regurgitation.  It  may  be  added  that  the  significance  of 
a  weakened  aortic  second  sound  is  enhanced  by  evidence  that  the 
left  ventricle  is  hypertrophied,  inasmuch  as,  under  these  circum- 
stances, the  aortic  second  sound  should  be  increased  rather  than 
diminished  in  iutensit}^,  provided  the  aortic  valves  are  sound  and 
mitral  regurgitation  does  not  take  place. 

Mitral  insufficiency  may  exist  either  with  or  without  mitral  con- 


190  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

traction,  and,  conversely,  the  latter  may  exist  with  or  -without  the 
former.  The  morbid  alterations  which  occur  in  this  situation, 
however,  involve  insufficiency  without  contraction  oftener  than 
contraction  without  insufficiency,  but  both  are  not  unfrequently 
combined.  It  follows  from  these  facts  that  a  mitral  direct  or 
diastolic  murmur  and  a  mitral  regurgitant  or  systolic  murmur 
may  exist  either  separately  or  conjointly;  that  the  existence  of  the 
former  alone  is  extremely  infrequent,  while  it  is  very  common  to 
meet  with  the  latter  by  itself,  and  that  the  instances  in  which  both 
are  conjoined  are  more  frequent  than  the  instances  in  which  the 
first  exists  separately.  Clinical  observation  confirms  the  correct- 
ness of  these  conclusions. 

A  mitral  regurgitant  murmur  was  first  recognized  as  such  by 
Dr.  Hope  in  1825.     It  was  first  described  by  Dr.  Elliottson  in  1830. 

3.  Aortic  Direct  or  Systolic  Murmur. — In  frequency  of  occurrence, 
this  ranks  next  to  the  murmur  last  noticed.  It  is  stated  by  some 
writers  that  it  occurs  oftener  than  either  of  the  other  murmurs. 
My  own  recorded  observations  do  not  lead  to  this  conclusion.  Of 
fifty-nine  cases  of  valvular  lesions  in  which  either  a  mitral  regurgi- 
tant or  aortic  direct  murmur  existed  separately,  the  former  was 
present  in  thirty-eight,  and  the  latter  in  twenty-one.  This  murmur, 
assuming,  for  the  present,  that  it  proceeds  from  organic  lesions, 
denotes  a  serious  affection,  or  otherwise,  according  to  the  effect  of 
the  lesions  as  regards  obstruction  at  or  near  the  aortic  orifice.  The 
physical  conditions  necessary  for  the  production  of  a  murmur  in 
this  situation  may  exist  without  obstruction.  Such  instances  are 
not  very  rare.  There  may  be,  under  these  circumstances,  no  im- 
mediate danger  and  no  troubles  referable  to  the  heart  affection. 
The  physical  conditions  giving  rise  to  the  murmur  may  remain  for 
an  indefinite  period  innocuous.  On  the  other  hand,  in  proportion 
as  obstruction  to  the  aortic  blood-current  is  involved,  evils  ensue, 
viz.,  accumulation  of  blood  in  the  ventricular  cavity ;  enlargement 
of  the  left  ventricle  by  dilatation  or  hypertrophy,  or  commonly 
both ;  enlargement  of  the  left  auricle,  pulmonar}'-  congestion,  and 
the  more  remote  consequences  which  are  essentially  those  also 
resulting  from  obstructive  and  regurgitant  lesions  of  the  mitral 
orifice.  There  are  no  constant  characters  pertaining  to  the  mur- 
mur itself  which  enable  the  auscultator  to  determine  whether  the 
lesions  do  or  do  not  involve  obstruction.  Marked  rousrhness  or  a 
musical  intonation  renders  it  highly  probable  that  there  is  contrac- 


AORTIC    DIRECT    OR    SYSTOLIC    MURMUR.  191 

tion  at  the  orifice,  due  to  expansion  and  rigidity  of  one  or  more 
segments  of  the  valve  or  the  presence  of  an  abundant  morbid 
deposit.  But  these  conditions  may  exist  without  roughness  of  the 
murmur  or  a  musical  intonation ;  and,  hence,  the  absence  of  the 
characters  just  named  is  not  evidence  against  the  existence  of 
obstructive  lesions.  It  is  a  point  of  importance  to  observe  the 
aortic  second  sound  of  the  heart.  If  this  sound  retain  its  normal 
intensity  and  purity,  it  shows  that  the  aortic  valve  is  competent  to 
fulfil  its  function,  a  fact  which  warrants  the  exclusion  of  lesions 
affecting  it  sufficiently  to  give  rise  to  obstruction.  In  a  large 
proportion  of  the  cases  of  obstructive  lesions  at  the  aortic  orifice, 
the  valve  is  involved  sufficiently  to  compromise,  to  a  greater  or 
less  extent,  its  function,  and  impair  the  intensity  of  the  aortic 
second  sound.  This  practical  point  is  to  be  borne  in  mind.  Aside 
from  this,  the  evidence  of  the  existence  of  obstruction,  and  also  of 
its  degree  and  duration,  must  be  derived  from  the  extent  of  en- 
largement of  the  left  ventricle  and  the  symptoms  dependent  on  the 
remote  effects  of  the  heart  affection.  The  cardiac  enlargement, 
however,  and  the  remote  effects  may  proceed  equally  from  aortic 
obstruction  and  aortic  regurgitation,  as  in  cases  of  mitral  lesions 
they  result  alike  from  contraction  and  insufficiency.  Enlargement 
of  the  heart  accompanying  valvular  lesions,  either  at  the  mitral  or 
aortic  orifice,  is,  in  general,  proportionate  to  the  amount  and  dura- 
tion of  obstruction  or  regurgitation,  or  both,  which  the  lesions 
involve.  The  enlargement  alone  does  not  enable  the  diagnostician 
to  discriminate  between  the  obstructive  and  regurgitant  lesions. 
As  regards  the  localization  of  lesions  at  the  mitral  or  aortic  orifice, 
assistance  is  derived  from  this  source,  which  will  be  referred  to  in 
connection  with  that  subject. 

4.  Aortic  Regurgitant  or  Diastolic  Murmur. — This  ranks  next  to  a 
mitral  direct  or  diastolic  murmur  as  regards  infrequency.  It  is 
more  frequently  met  with  than  the  latter,  but  much  less  frequently 
than  the  two  other  murmurs.  An  important  fact  which  was  stated 
in  connection  with  the  notice  of  the  mitral  regurgitant  or  systolic 
murmur,  is  equally  true  with  respect  to  the  murmur  under  present 
notice,  viz :  A  murmur  may  be  produced  when  no  regurgitation 
takes  place.  Clinical  experience  has  abundantly  shown  that  in 
some  instances  a  diastolic  murmur  referable  to  the  aortic  orifice 
exists,  the  aortic  valve  remaining  sufficient.  This  occurs  when, 
owing  to  roughness  of  the  lining  membrane  of  the  aorta  above  the 


192  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

valve,  dilatation  of  the  artery  on  the  one  hand,  or  contraction  on 
the  other  hand,  the  retrograde  movement  of  the  column  of  blood, 
in  this  vessel,  succeeding  the  ventricular  systole,  suffices  to  give 
rise  to  audible  sonorous  vibrations,  althoagh  no  blood  falls  back- 
wards into  the  ventricle.  The  gravity  of  the  lesions  represented  by 
a  diastolic  murmur  referable  to  the  aorta,  depends  mainly  on  the 
existence  of  insufficiency  and  the  amount  of  regurgitation.  What 
circumstances,  then,  associated  with  this  murmur,  enable  the  aus- 
cultator  to  decide  whether  regurgitation  takes  place  or  not  ? 
Attention  to  the  aortic  second  sound  of  the  heart  is  of  importance 
Avith  reference  to  this  question.  Has  this  sound  its  normal  intensity 
and  valvular  quality  unimpaired,  the  inference  is  that  the  valve  is 
not  to  much  extent,  if  at  all,  insufficient.  Is  the  sound  weakened 
and  its  normal  quality  not  distinctly  defined,  this  is  evidence  that 
the  valve  is  involved  so  as  to  compromise  its  competenc}^  to  fulfil 
its  function,  and  consequently  that  regurgitation  takes  place.  Is 
the  sound  extinguished,  as  is  sometimes  observed,  either  destruc- 
tion or  rigid  expansion  of  the  several  segments  of  the  valve  has 
probably  taken  place.  The  degree  to  which  the  sound  is  impaired 
may  be  taken  as,  in  a  measure  at  least,  a  criterion  of  the  amount 
of  damage  which  the  valve  has  received.  Another  point  relating  to 
this  question  is  the  diffusion  of  the  murmur.  If  aortic  regurgita- 
tion take  place,  the  retrograde  current  of  blood  carries  the  mur- 
mur downwards  so  that  it  may  be  discovered  over  the  body  of  the 
heart  within  the  superficial  cardiac  region,  and  sometimes  at  the 
apex  or  even  below  the  heart.  This  transmission  rarely,  if  ever, 
takes  place  when  a  diastolic  aortic  murmur  exists  which  .is  not 
regurgitant.  Under  these  circumstances  it  may  be  propagated 
upwards  even  into  the  carotids,  but  to  a  limited  extent,  if  at  all, 
below  the  base  of  the  heart. 

An  aortic  direct  or  systolic  murmur  and  an  aortic  regurgitant  or 
diastolic  murmur,  may  be  present  singly  or  combined.  Regurgita- 
tion may  take  place  without  murmur,  even  when  the  physical  con- 
ditions exist,  owing  to  the  force  of  the  retrograde  current  being 
too  feeble  to  occasion  sonorous  vibrations.  Absence  of  an  aortic 
regurgitant  murmur,  therefore,  is  not  positive  proof  that  there  is 
no  regurgitation.  In  the  majority  of  the  cases  in  which  the  lesions 
of  the  aortic  valve  are  such  as  to  give  rise  to  a  regurgitant  murmur, 
the  conditions  for  the  production  of  a  direct  or  systolic  murmur 
co-exist.     The  aortic  direct  and  aortic  reofuroitant  murmurs,  conse- 


DETERMINATION    OF    TUE    SEAT    OF    LESIONS.  193 

quentlj,  are  associated  oftener  than  the  latter  is  observed  discon- 
nected from  the  former. 

The  two  murmurs  produced  at  each  of  the  two  orifices,  viz.,  the 
mitral  and  aortic,  are  not  very  infrequently  presented  in  combina- 
tion. The  aortic  and  mitral  murmurs  may  also  be  associated  in, 
the  same  case.  Instances  of  the  union  of  a  mitral  and  an  aortic 
murmur  are  sufficiently  common.  I  have  frequently  met  with 
three  distinct  co-existing  murmurs ;  and  it  is  quite  possible  for  all 
four  to  be  simultaneously  present  and  distinguishable.  It  is  con- 
ceivable, indeed,  that  eight  distinct  murmurs  may  be  combined  in 
the  same  case,  tricuspid  and  pulmonic  murmurs  corresponding  to 
those  produced  in  the  left  side  of  the  heart,  being  present.  The 
latter  murmurs  are  so  extremely  rare  that  it  is  not  necessary  to 
consider  them  in  this  connection.  We  come  now  to  the  considera- 
tion of  the  means  by  which  the  different  murmurs,  respectively, 
are  localized  and  discriminated  from  each  other. 


Can  the  particular  seat  of  valvular  lesions  be  determined,  and,  if  so,  in 

what  manner  ? 

The  first  part  of  this  inquiry  has  been  already  answered.  It  has 
been  stated  that  it  is  practicable,  generally,  to  localize  valvular 
lesions.  The  mode  in  which  this  may  be  done  is  now  to  be  con- 
sidered. To  refer  a  murmur  to  a  particular  valve  or  orifice  seems, 
to  one  unacquainted  with  the  subject,  to  be  a  refinement  in  diag- 
nosis not  only  difficult,  but  invested  with  an  air  of  mystery.  The- 
rules,  however,  are  extremely  simple;  their  application  is  by  no- 
means  intricate,  nor  does  it  require  the  exercise  of  any  extraordi- 
nary skill  or  tact.  The  points  involved  in  determining  the  par- 
ticular seat  of  lesions,  relate,  1st.  To  their  relations  to  the  heart- 
sounds;  2d.  To  the  different  situations  in  which  murmurs  are 
found  to  be  most  intense,  and  the  different  directions  in  which  they 
are  farthest  propagated ;  3d.  To  the  pitch  and  quality  of  the  mur- 
mur ;  and,  4th.  To  the  condition  of  the  heart-sounds  considered  in. 
connection  with  the  murmurs.  In  treating  of  this  branch  of  the 
subject,  it  will  be  most  convenient  to  consider  the  murmurs  as 
embraced  in  two  classes,  viz:  systolic  and  diastolic,  ^.  e.,  accompany- 
ing either  the  first  or  the  second  of  the  heart  sounds.  The  reader,, 
however,  will  continue  to  bear  in  mind  that  a  systolic  murmur  may 
be  either  an  aortic  direct,  or  a  mitral  regurgitant  murmur ;  and 
that  a  diastolic  murmur  may  be  either  a  mitral  direct,  or  an  aortic 
13 


191  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

regurgitant  murmur.  These  names,  derived  from  the  relations  of 
the  murmurs  to  the  different  blood-currents  which  have  been  de- 
scribed, are  extremely  useful  in  fixing  these  relations  in  the  memory. 

Localization  of  Systolic  Murmurs. — In  tracing  an  endocardial  mur- 
mur to  its  source,  the  first  point  is  to  ascertain  whether  it  be  a 
S3^stoliG  or  a  diastolic  murmur.  Generally  this  is  unattended  with 
difficulty;  but  in  some  instances  it  is  not  easy.  The  difficulty 
arises  from  the  rapidity  of  the  heart's  action.  If  the  heart  sounds 
recur  with  great  frequency,  the  systolic  and  diastolic  sounds  are 
not  readily  distinguishable  from  each  other.  The  two  sounds 
follow  each  other  so  quickly  that  the  difference  in  duration  between 
the  two  pauses  or  intervals  is  scarcely  apparent.  Moreover,  under 
these  circumstances,  the  first  sound  frequently  loses  its  distinctive 
characters  as  regards  its  relative  length,  quality,  and  even  pitch, 
and  the  two  sounds  become  nearly  or  quite  identical.  Occasionally 
the  two  sounds  cannot  be  discriminated,  until  the  frequency  of  the 
ventricular  contractions  diminishes,  or  is  reduced  by  certain  sedative 
remedies,  such  as  digitalis,  or  the  veratrum  viride.  When  the  two 
sounds  are  with  difficulty  distinguishable  from  each  other,  it  is,  of 
course,  proportionately  difficult  to  determine  which  of  the  sounds 
an  existing  murmur  accompanies.  This  difficulty,  happily,  is  ex- 
perienced in  only  a  small  proportion  of  cases.  In  the  few  instances 
in  which  a  murmur  cannot  be  referred  to  either  sound,  the  localiza- 
tion of  lesions  is  thereby  made  with  less  ease  and  positiveness.  The 
rules,  however,  are  still  measurably  available.  Whenever  the 
rapid  action  of  the  heart  does  not  give  rise  to  difficulty,  the  different 
characters  as  regards  length,  quality  and  pitch,  which  belong  to  the 
first  or  systolic  sound,  enable  the  auscultator  to  distinguish  it  with 
readiness.  These  characters  have  been  already  described.^  If  any 
doubt  arise,  with  the  finger  upon  the  pulse  of  the  patient  while 
auscultation  is  practised,  it  is  easy  to  determine  with  which  of  the 
two  sounds  the  pulse  is  synchronous,  or  nearly  so.  The  sound 
which  occurs  synchronously  with  the  pulse  is,  of  course,  the  systolic 
sound. 

Assuming  that  a  murmur  has  been  ascertained  to  be  systolic, 
it  may  be  either  a  mitral  regurgitant  or  an  aortic  direct  murmur. 
The  question  which  next  arises  is,  how  is  it  to  be  traced  to  the 
mitral  or  to  the  aortic  orifice?  If  it  be  mitral,  its  maximum  of 
intensity  is  at  or  near  the  apex  of  the  heart.     In  some  instances  it 

'  Chapter  L 


LOCALIZATION    OF    SYSTOLIC    MURMURS.  195 

is  most  intense  at  the  point  where  the  apex-beat  is  feeen,  felt,  or 
determined  by  auscultation.  In  other  instances  the  intensity  is 
greatest  at  a  little  distance  to  the  left  of  the  point  of  apex-beat. 
When  the  latter  is  the  case,  the  explanation  is  probably  that  given 
by  Dr.  Sibson,  viz  :  the  murmur  is  somewhat  obscured  directly  over 
the  apex,  by  the  intensity  of  the  first  sound,  and  sometimes  by  tin- 
nitus.' The  murmur  may  be  confined  within  a  circumscribed  space 
around  the  apex.  It  is  generally  heard  over  the  body  of  the  heart, 
within  the  superficial  cardiac  region,  but  with  diminished  intensity. 
Above  the  base  of  the  heart  it  is  often  feeble  or  wanting.  It  is  not 
propagated  into  the  carotids.  If  it  be  transmitted  to  the  upper 
part  of  the  chest,  as  is  sometimes  observed  when  it  is  unusually 
loud,  the  intensity  is  much  less  than  over  the  body  and  apex,  or 
below  the  heart.  It  is  often  diffused  over  the  left  lateral  surface  of 
the  chest,  and  may  extend  to  the  posterior  surface  on  the  left,  and 
sometimes  on  the  right  side.  When  heard  on  the  back,  its  intensity 
is  greater  below  than  above  the  spinous  ridge  of  the  scapula,  the 
maximum  being  generally  near  the  lower  angle  of  the  scapula. 
The  quality  of  the  murmur  may  be  soft  or  rough.  It  is  soft  in  the 
great  majority  of  cases.  Eoughness,  however,  belongs  almost  ex- 
clusively to  systolic  murmurs.  Diastolic  murmurs,  at  least,  much 
more  rarely  than  the  systolic,  present  this  quality.  It  very  rarely 
has  a  musical  intonation  in  this  situation.  The  pitch  varies  in  dif- 
ferent cases,  but,  as  a  rule,  is  neither  extremely  high  nor  low.  It 
is  rarely  as  high  as  the  letter  R  whispered,  and  still  more  rarely  as 
high  as  S.  It  is  seldom  as  low  as  awe.  In  the  larger  number  of 
instances,  it  is  represented  by  who.  The  mitral  valvular  element 
of  the  first  of  the  heart-sounds  is  frequently  diminished-  or  wanting, 
leaving  the  element  of  impulsion  unduly  predominant  or  solely 
present.^  The  diminution  of  this  element  is  in  proportion  to  the 
injury  of  the  valve  which  the  lesions  have  occasioned,  and  its  absence 
shows  that  the  valve  is  nearly  or  quite  useless.  The  aortic  second 
sound  is  diminished  in  intensity  in  proportion  to  the  amount  of 
blood  which  regurgitates  through  the  mitral  orifice.  The  pulmonic 
second  sound  is  thereby  rendered  relatively  more  intense,  and  its 
intensity  is  often  positively  augmented  by  obstruction  to  the  pul- 
monary circulation  and  hypertrophy  of  the  right  ventricle. 

'  Medical  Anatomy. 

2  For  an  account  of  the  two  elements  of  the  first  or  systolic  sound,  and  the  man- 
ner of  exploring  for  the  mitral  and  tricuspid  valvular  elements  of  this  sound,  the 
reader  is  referred  to  Chapter  I.  page  60,  et  seq. 


196  PHYSICAL    SIGNS    OF    VALVULAR    LESIOXS. 

The  foregoing  points  distinguish  a  mitral  regurgitant  systolic 
murmur.  If,  on  the  other  hand,  a  systolic  murmur  be  an  aortic 
direct  murmur,  its  maximum  of  intensity  is  at  or  above  the  base  of 
the  heart.  Its  intensity  is  less  over  the  body  of  the  heart,  within 
the  superficial  cardiac  region,  than  at  the  base,  and  it  may  be  lost 
in  the  latter  situation.  It  is  still  more  feeble  and  is  often  lost 
over  the  apex  ;  and  it  is  very  rarely  propagated  below  this  point. 
The  particular  situation  where  it  is  most  intense,  is  usually  in  the 
second  or  third  intercostal  spaces  nigh  to  the  sternum.  In  the 
third  intercostal  space  on  the  left  side  nigh  to  the  sternum  the 
intensity  is,  in  general,  notably  less  than  at  the  corresponding  point 
on  the  right  side.  From  the  base  of  the  heart  it  is  propagated 
upwards  for  a  greater  or  less  distance,  more  so  on  the  right  than  on 
the  left  side.  It  is  often  pretty  loud  at  the  sternal  notch.  It  is 
•iieard  in  the  neck  over  the  carotids.  It  is  sometimes  heard  on  the 
posterior  surface  of  the  chest,  and  when  this  is  the  case  its  maximum 
is  in  the  left  interscapular  space  on  a  level  with  the  spinous  ridge 
of  the  scapula.  It  is  soon  lost  below  this  point.  The  murmur 
may  be  soft  or  rough,  the  latter  quality  being  much  less  frequent 
than  the  former.  It  is,  however,  oftener  rough  than  a  systolic  mitral 
regurgitant  murmur.  The  pitch  is  usually  higher  than  in  the  ma- 
jority of  the  instances  of  a  mitral  regurgitant  murmur,  often  being 
represented  by  the  letter  E,  whispered.  The  pitch,  however,  varies 
considerably  in  different  cases.  It  has  a  musical  intonation  oftener 
than  a  mitral  regurgitant  murmur.  The  aortic  second  sound  of 
the  heart  is  frequently  impaired  and  may  be  extinguished,  the 
pulmonic  second  sound  remaining.'  The  extent  to  which  this 
sound  is  compromised,  will,  of  course,  correspond  to  the  amount  of 
injury  to  the  aortic  valves  incident  to  the  lesions  which  give  rise  to 
the  murmur. 

As  already  stated,  the  two  systolic  murmurs  may  be  associated 
in  the  same  case.  This  fact  can  generally  be  determined.  The 
murmurs  are  rarely  identical  in  quality  and  pitch ;  and  each  mur- 
mur has  its  maximum  of  intensity  in  different  situations,  and  con- 
forms to  the  characters  which  distinguish,  on  the  one  hand,  a  mitral 
regurgitant,  and  on  the  other  hand,  an  aortic  direct  murmur.  As 
a  rule,  the  two  murmurs  in  the  same  case  may  be  localized  with  as 

'  The  situations  in  wliicli  the  aortic  and  pulmonic  second  sounds  may  be  studied 
separately,  are  the  second  intercostal  sjjaces  on  the  right  and  left  side  of  the  ster- 
num.    See  Chapter  I.  page  59. 


LOCALIZATION    OF    DIASTOLIC    MURMURS.  197 

much  precisien,  as   when  either  is  present  without  the  other  in 
different  cases. 

Localization  of  Diastolic  Murmurs. — A  murmur  having  been 
ascertained  to  be  diastolic,  i.  e.,  sustaining  a  closer  relation  to  the 
second  than  to  the  first  sound  of  the  heart,  the  question  to  be  then 
settled  is,  whether  it  be  a  mitral  direct  murmur  or  an  aortic  regur- 
gitant murmur.  The  points  involved  in  this  discrimination  are 
less  strongly  marked  than  in  the  case  of  the  systolic  murmurs. 
But  in  most  instances  the  distinction  can  be  made  with  proper 
knowledge  and  care, 

A  mitral  direct  murmur,  as  before  stated,  is  strictly  speaking 
pre-systolic.  It  occurs  just  before  the  first  or  systolic  sound,  and 
may  be  continued  into  that  sound.  This  is  due  to  the  fact  that 
the  contraction  of  the  left  auricle  precedes,  by  a  very  short 
interval,  the  contraction  of  the  left  ventricle,  the  latter  appearing 
to  be  a  continuation  of  the  former.  This  is  apparent  on  examin- 
ing the  movements  of  the  heart  exposed  to  view  in  vivisections  prac- 
tised on  animals  of  large  size,  and  in  cases  of  ectopia.  The  murmur 
is  usually  accompanied  by  a  systolic  mitral  regurgitant  murmur,  the 
same  lesions  giving  rise  to  both.  Its  maximum  of  intensity  is  over 
the  body  or  apex  of  the  heart.  It  is  rarely  diffused  in  any  direction 
without  the  pra3Cordia.  It  is  feeble  or  not  distinguishable  at  the 
base  of  the  heart.  The  murmur  is  rarely  intense,  and  in  the  vast  ma- 
jority of  cases  its  quality  is  soft.  The  pitch  is  usually  low.  It  may  be 
represented  by  the  whispered  word  awe.  The  mitral  valvular  ele- 
ment of  the  first  sound  may  be  more  or  less  impaired,  but  the  aortic 
second  sound  (assuming  that  aortic  lesions  do  not  co-exist)  preserves 
its  normal  intensity.  The  latter  is  an  important  point  in  discriminat- 
ing this  murmur  from  an  aortic  regurgitant  murmur.  The  pulmonic 
second  sound  is  not,  only  relatively  more  intense  than  the  aortic  in 
consequence  of  the  diminished  intensity  of  the  latter,  but  is  positively 
intensified,  mitral  contraction  generally  existing  when  this  mur- 
mur is  present,  and,  as  a  consequence,  pulmonary  congestion  and 
hypertrophy  of  the  right  ventricle. 

If  the  diastolic  murmur  be  an  aortic  regurgitant  murmur,  it 
either  replaces  or  follows  more  closely  upon  the  second  sound 
than  a  direct  mitral  murmur.  It  is  due  to  the  same  force  which 
causes  the  aortic  second  sound,  viz.,  the  recoil  of  the  elastic  coat 
of  the  aorta,  while  the  mitral  direct  murmur  is  produced,  by  the 
contraction  of  the  left  auricle.     The  former  occurs  prior  to  the 


198  PHYSICAL    SIGXS    OF    VALVULAR    LESIONS. 

latter,  and  hence  the  corresponding  murmur  takes  precedence  in 
point  of  time.  The  intensity  of  this  murmur  is  not,  as  is  stated  by- 
some  writers,  greatest  at  the  base  of  the  heart,  but  below,  over  the  body 
of  the  organ,  nigh  to  the  left  margin  of  the  sternum.  It  is,  however, 
more  likely  to  be  heard  at  the  base,  in  the  second  intercostal  space 
on  the  right  side  of  the  sternum,  than  a  mitral  direct  murmur,  and 
this  is  an  important  point  of  distinction.  It  is  generally  feeble  and 
very  rarely  rough  in  quality.  The  pitch  is  usually  low.  In  most 
instances  it  is  associated  with  a  systolic  aortic  direct  murmur,  the 
same  lesions  giving  rise  to  both  murmurs.  The  aortic  second 
sound  is  usually  more  or  less  impaired,  and  in  some  instances  is 
extinguished.  A  notable  diminution  of  the  intensity  of  this  sound 
or  its  extinction,  provided  neither  mitral  contraction  nor  regurgita- 
tion co-exists,  is  'proof  positive  that  the  diastolic  murmur  has  its 
source  in  aortic  regurgitation.  On  the  other  hand,  the  integrity  of 
the  aortic  sound  and  a  diminished  intensity  of  the  mitral  valvular 
element  of  the  first  sound,  constitute  hardly  less  proof  that  a  dias- 
tolic murmur  is  referable  to  the  mitral  orifice.  Intensification  of 
the  pulmonic  second  sound  occurs  as  a  more  remote  and  less  con- 
stant result  than  in  connection  with  the  lesions  which  give  rise  to 
a.  mitral  direct  murmur. 

The  two  diastolic  murmurs  may  be  associated  in  the  same  case, 
but  instances  of  this  combination  are  vastly  less  frequent  than  the 
union  of  the  systolic  murmurs.  It  is.  however,  as  already  stated, 
very  common  for  one  or  both  of  the  systolic  murmurs  to  be  asso- 
ciated with  a  diastolic  murmur.  Examples  of  three  murmurs,  two 
systolic  and  one  diastolic,  are  not  very  infrequent.  Usually,  each 
may  be  referred  to  its  source.  It  is  not  claimed  that  the  rules  of 
localization  which  have  been  briefly  pointed  out  are  infallible. 
Exceptional  instances  will  occur  in  which  the  source  of  a  murmur 
is  uncertain.  But  in  the  great  majority  of  cases  it  is  determinable 
without  much  doubt  or  difficulty.  This  statement  is  based  on  con- 
siderable practical  experience,  and  on  the  anah'sis  of  a  large 
number  of  recorded  cases. 

To  assist  the  reader  in  fixing  in  the  memory  the  points  involved 
in  the  localization,  which  have  just  been  considered,  the  following 
tabular  view  is  added  : — 


LOCALIZATION    OF    MURMUES. 


199 


RECAPITULATION  OF  POINTS  INVOLVED  IN  THE  LOCALIZATION  OF  SYSTOLIC  AND 
DIASTOLIC  MURMURS. 


SYSTOLIC  MURMURS 
Mitral  Regurgitant. 

Maximum  of  intensity  at  or  near  the 
apex  of  the  heart.  Comparatively 
feeble  or  wanting;  at  the  base. 


Not  propagated  above  the  base  of  the 
heart.     Not  heard  over  carotids. 

Often  dilTused  over  left  lateral  surface  of 
chest. 

If  heard  in  the  interscapular  space,  most 
intense  near  the  lower  angle  of  sca- 
pula. 

Aortic  second  sound  weakened  but  dis- 
tinct. 

Pulmonic  second  sound  intensified. 

Mitral  valvular  element  of  the  first  sound 
more  or  less  impaired. 


Aortic  Direct. 
JIaximum  of  intensity  at  or  above  the 

base  of  the  heart  in  the  second  or  third 

intercostal  space,  near  the   sternum. 

Intensity    notably    diminished     over 

body  of  heart  and  at  the  apex. 
Propagated  above  the  base  of  the  heart, 

and  often  heard  over  carotids. 
Piarely  heard  over  left  lateral  surface  of 

chest. 
If  heard  in  the  interscapular  space,  most 

intense  as  high  as  the  spinous  ridge  of 

scapula. 
Aortic  second  sound  often  more  or  less 

indistinct. 
Pulmonic  second  sound  less  frequently 

intensified. 
Mitral  valvular  element  of  the  first  sound 

not  impaired. 


The  murmur,  in  a  certain  proportion  of  cases,  rough,  but,  in  the 
majority  of  instances,  soft. 

The  pitch  varying,  in  the  majority  of  cases,  between  the  sounds 
represented  by  the  letter  K  and  the  sylhible  who,  whispered. 


DIASTOLIC  MURMURS 
Mitral  Direct. 

Occurs  just  before  the  systolic  or  first 

sound. 
Often  associated  with  a  systolic  mitral 

regurgitant  murmur. 
Maximum  of  intensity  over  body  or  apex 

of  heart. 
Feeble  and  often  not  appreciable  at  the 

base  of  the  heart. 
Mitral  valvular  element  of  first  sound 

may  be  impaired. 
Aortic  second  sound  may  be  normal. 


Pulmonic  second  sound  intensified. 


Aortic  Regurgitant. 
Replaces  or  follows  closely  the  diastolic 

or  second  sound. 
Often  associated  with  a  systolic   aortic 

direct  murmur. 
Maximum  of  intensity  over  body  of  heart, 

near  the  sternum. 
Generally  appreciable  at  the  base  of  the- 

heart. 
Mitral  valvular  element  of  first  sound. 

not  impaired. 
Aortic  second  sound  often  impaired  and' 

sometimes  extinguished. 
Pulmonic  second  sound  less  frequently" 

intensified. 


Always  feeble  in  comparison  with  the  intensity  Avhich  systolic 
murmurs  often  present. 

The  quality  almost  invariably  soft. 


200  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

.   The  pitch  generally  lower  than  systolic  murmurs;  often  repre- 
sented by  the  whispered  word  awe. 

Rarely  diffused  without  the  pra3Cordial  region. 


Pathological  Import  or  Organic  Endocardial  Murmurs. 

It  is  highly  important  for  the  student  to  form  a  just  notion  of 
the  extent  to  which  organic  murmurs  are  available  in  furnishing 
information  respecting  pathological  conditions.  The  considerations 
"which  have  been  presented  have  related  mainly  to  diagnosis. 
They  show  that  organic  lesions  are  accompanied  by  an  organic 
murmur  in  the  great  majority  of  cases ;  and,  conversely,  the  absence 
of  murmur  renders  it  almost  certain  that  organic  lesions  do  not 
exist.  So  far,  the  practical  value  of  auscultation  in  this  applica- 
tion is  very  great.  Further  than  this,  valvular  lesions  may  gene- 
rally be  localized  at  one  or  more  of  the  orifices  of  the  heart  by 
attention  to  certain  points  pertaining  to  the  murmurs.  Moreover, 
the  study  of  the  murmurs  enables  the  auscultator  often  to  deter- 
mine whether  obstruction  or  regurgitation,  or  both,  at  one  or  more 
of  the  orifices,  are  consequent  on  existing  lesions.  These  ends  are 
sufficiently  important  to  render  invaluable  the  aid  thus  derived 
from  auscultation.  The  information,  however,  derived  from  the 
murmurs  is  limited  mainly  to  these  ends.  The  character  of  the 
structural  changes  which  have  taken  place,  and  the  amount  of 
damage  which  they  have  occasioned,  are  to  be  determined  by  other 
means  than  the  study  of  the  murmurs.  In  a  practical  view,  it  is 
far  more  important  to  establish  these  points  than  the  mere  exist- 
ence of  organic  lesions  of  some  kind,  or  their  particular  situation 
and  immediate  effects  on  the  blood-currents.  In  determining  these 
points,  the  heart-sounds  are  to  be  studied  with  reference  to  abnor- 
mal modifications,  or  otherwise,  and  the  existence  and  extent  of 
enlargement  of  the  heart  are  to  be  ascertained.  The  means  of 
ascertaining  the  existence  of  cardiac  enlargement  and  measuring  its 
extent  have  been  fully  considered  in  a  former  chapter.  Abnormal 
modifications  of  the  heart-sounds,  in  connection  with  endocardial 
murmurs,  have  also  been  referred  to.  The  latter  will  be  again 
noticed  presently  under  a  distinct  head. 

It  is  to  be  borne  in  mind  that  lesions  which  are  innocuous  as  re- 
gards any  immediate  effects,  i.  e.,  which  do  not  occasion  either 
obstruction  or  regurgitation,  may  give  rise  to  murmurs.    Fibrinous 


PATHOLOGICAL    KEPORT    OF    MURMURS.  201 

or  calcareous  deposits  on  the  valves,  orifices,  or  within  the  aorta, 
without  valvular  insufficiency,  contraction  or  dilatation,  may  supply 
the  physical  conditions  for  audible  sonorous  vibrations.  Dilatation 
of  the  cavities  of  the  heart  is  said  sometimes  to  give  rise  to  a  mur- 
mur, which  has  been  attributed  to  a  disproportion  between  the  size 
of  the  cavities,  and  the  quantity  of  circulating  blood.  Without 
denying  the  possibility  of  the  production  of  a  murmur  under  these 
circumstances,  it  is  certainly  an  event  of  extremely  rare  occurrence. 
Dilatation  without  over-distension  is  an  anomaly  which  rarely 
occurs.  A  more  rational  explanation  is  to  attribute  the  murmur, 
when  produced,  to  an  abnormal  condition  of  the  blood,  an  explana- 
tion which  brings  the  murmur  into  tlie  class  of  inorganic  murmurs. 
Serious  lesions  are  by  no  means  to  be  predicated  on  the  existence 
of  a  murmur  which  is  undoubtedly  of  organic  origin.  This  is  the 
practical  precept  to  be  enforced.  Nor  is  the  intensity  of  a  murmur 
to  be  taken  as  any  criterion  of  the  importance  of  the  lesions  which 
give  rise  to  it.  An  intense  murmur  may  accompany  trivial  lesions, 
and,  on  the  other  hand,  the  most  serious  lesions  may  give  rise  to  a 
feeble  murmur.  Indeed,  as  remarked  by  Dr.  Walshe,  feebleness  of 
the  murmur  may,  in  some  instances,  constitute  evidence  of  the 
gravity  of  lesions,  showing  that  the  heart  has  become  weakened  by 
the  dilatation  and  over-distension  of  its  cavity  incident  to  the  lesions. 
Roughness  of  a  murmur  also,  it  is  to  be  recollected,  is  no  guide  to 
the  nature  or  extent  of  the  structural  changes  which  it  indicates. 
The  same  remark  is  applicable  to  the  diffusion  of  a  murmur,  when 
it  is  aortic.  Diffusion  of  a  mitral  regurgitant  murmur,  on  the  other 
hand,  without  the  prascordial  region,  may,  in  general,  be  considered 
as  denoting  regurgitation ;  but  it  is  in  nowise  a  criterion  of  the 
amount  of  regurgitation,  or,  in  other  words,  valvular  insuflSciency. 
An  organic  murmur  is  in  some  instances  neither  propagated 
above  the  heart,  nor  diffused  in  any  direction  beyond  the  heart,  but 
confined  within  the  limits  of  the  preecordial  region.  The  lesions 
giving  rise  to  the  murmur  in  these  instances  are  within  the  left 
ventricle,  and  may  be  situated  either  on  the  ventricular  aspect  of 
either  the  mitral  or  aortic  valve.  It  is  difficult  or  impossible  to 
localize  the  lesions  under  these  circumstances.  For  an  example, 
in  a  case  in  which  vegetations  of  considerable  size  were  dependent 
from  the  inferior  surface  of  the  aortic  valve,  the  valve  not  being 
otherwise  affected,  the  murmur  was  confined  to  the  region  of  super- 
ficial cardiac  dulness,  its  maximum  of  intensity  not  being  marked 
at  any  point  within  this  space.     Murmurs  of  this  description  may 


202  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS, 

be  distinguished  as  intra-ventricidar  murmurs^^  and  the  inference  to 
be  drawn  from  them  is  that  the  valves  are  not  afiected  to  the  extent 
of  interrupting  materially  their  functions. 

In  treating  of  the  subject  of  endocardial  organic  murmurs  in  this 
chapter,  reference  has  been  had,  for  the  most  part,  to  those  occur- 
ring in  connection  with  chronic  valvular  affections  of  the  heart. 
Organic  murmurs,  as  will  be  seen  hereafter,  also  occur  in  connection 
with  heart-clots,  in  cases  of  congenital  malformations,  and  their 
production  becomes  an  important  physical  sign  of  the  development 
of  endocarditis.  Without  due  attention,  murmurs  taking  place 
within  an  aortic  aneurism  situated  near  the  heart,  are  liable  to  be 
mistaken  for  endocardial  murmurs. 


Inorganic  Murmurs. 

As  already  defined,  a  murmur  is  inorganic  when  it  is  produced 
independently  of  organic  or  structural  lesions.  An  endocardial 
murmur  may  be  present  when  there  are  no  lesions.  The  practical 
importance  of  being  able  to  determine  whether  an  existing  murmur 
be  organic  or  inorganic  is  sufficiently  obvious.  This  discrimination, 
happily,  can  be  made  in  practice  in  the  great  majority  of  cases. 
The  points  involved  in  the  discrimination  claim  attention  in  this 
connection. 

An  inorganic  murmur,  as  a  rule,  proceeds  from  an  abnormal 
change  in  the  composition  and  properties  of  the  blood.  The  precise 
nature  of  the  change  is  perhaps  not  positively  ascertained.  At  all 
events,  a  discussion  of  this  subject  need  not  be  here  introduced. 
Whatever  be  the  requisite  conditions,  they  occur  in  a  certain  pro- 
portion of  cases  of  anaemia  and  chlorosis.  The  murmur  in  these 
instances  is  said  to  be  of  luemic  origin.  It  was  observed  by  Mar- 
shall Hall,  in  his  researches  on  the  effects  of  the  loss  of  blood,  that 
the  sudden  abstraction  of  a  large  quantity  of  blood  led  to  the  deve- 
lopment of  a  transient  bellows-murmur.  Other  observers  have 
verified  this  fact.  It  is  occasionally  observed  under  circumstances 
which  seem  to  render  it  probable  that  it  proceeds  from  deficient  or 
irregular  contraction  of  the  papillary  muscles,  involving  temporary 

'  Intra-ventricular,  in  distinction  from  murmurs  produced  at  the  orifices  and  pro- 
pagated for  a  greater  or  less  distance  beyond  the  heart,  either  above  the  base,  if 
the  lesions  are  aortic,  or  to  the  left  of  the  heart  if  the  lesions  are  mitral  and  involve 
insufficiency. 


IXORGAXIC    MURMURS.  203 

insufficiency  and  regurgitation.  Its  occurrence  in  some  cases  of 
cliorea  has  been  accounted  for  in  this  way.  Thus  produced,  the 
murmur  is  said  to  be  of  dynamic  origin.  It  is  produced  in  some 
persons  in  health  by  the  violent  action  of  the  heart  which  follows 
active  muscular  exertion,  disappearing  when  the  organ  resumes 
its  usual  tranquillity.  It  is  occasionally  observed  in  the  course  of 
a  variety  of  affections,  when  post-mortem  examinations  in  cases  of 
death,  and  its  disappearance,  leaving  no  signs  or  symptoms  of 
cardiac  disease,  after  recovery,  show  that  it  does  not  proceed  from 
organic  causes.  The  continued  and  eruptive  fevers,  uraemia,  and 
hysteria,  are  among  the  affections  in  which  it  sometimes  occurs.  Its 
occurrence  is  not  infrequent  during  pregnancy.  What  are  the 
characters  which  distinguish  these  murmurs  from  those  of  organic 
origin? 

Inorganic  murmurs  are  uniformly  systolic,  i.  e.,  they  accompany 
only  the  first  of  the  heart-sounds.  Diastolic  murmurs  are  always 
of  oro-anic  orisrin. 

In  the  vast  majority  of  cases,  inorganic  murmurs  are  heard  at 
the  base  of  the  heart,  and  are  not  propagated  far  above,  and,  more 
especially,  not  below  this  point.  They  are  very  rarely  heard  at  the 
apex,  but  if  propagated  to  the  apex,  their  maximum  is  at  the  base. 
This,  at  least,  is  true  of  all  cases  of  inorganic  murmurs  of  Acemzc  origin. 
It  is  only  the  very  rare  and  somewhat  dubious  instances  of  murmurs 
of  dynamic  origin,  that  are  produced  at  the  auriculo-ventricular 
orifices,  and,  consequently,  heard  at  the  apex.  These  are  charac- 
terized by  temporary  duration  or  intermittency.  Hence,  it  may  be 
stated  that,  as  a  rule,  every  persistent,  constant  murmur  referable 
to  the  mitral  orifice,  denotes  organic  lesion  of  some  kind,  and,  as  a 
rule,  organic  murmurs  are  constant  and  persistent,  while  inorganic 
murmurs,  wherever  produced,  are  fluctuating  and  variable,  being 
sometimes  discoverable  only  when  the  body  is  in  a  certain  position. 

An  inorganic  murmur  is  uniformly  soft.  If  this  rule  be  not 
invariable,  the  exceptional  instances  are  exceedingly  infrequent, 
and  the  roughness  in  exceptional  instances  is  not  marked,  nor  con- 
stant, occurring  only  when  the  action  of  the  heart  is  unusually 
excited.  Eoughness,  therefore,  may  be  considered  as  evidence 
that  the  murmur  is  organic.  This  statement  will  apply  equally  to 
an  endocardial  musical  murmur.  An  inorganic  murmur  is  always 
feeble.     Intensity  is  evidence  of  organic  origin. 

An  inorganic  murmur  may  be  produced  either  at  the  aortic  or 
pulmonic  orifice,  or  simultaneously  at  both  orifices.     If  it  be  pul- 


20i  PHYSICAL    SIGNS    OF    VALVULAE    LESIONS, 

monic,  as  shown  by  its  being  either  limited  to,  or  having  its  maxi- 
mum of  intensity  in  the  left  second  or  third  intercostal  space,  it  is 
probably  inorganic,  in  view  of  the  great  infrequency  of  lesions 
situated  at  this  orifice.  Congenital  malformations  are  to  be  excluded 
from  this  statement,  for  these  are  more  liable  to  affect  the  pulmonic 
than  the  aortic  orifice.  In  this  connection  it  may  be  mentioned 
that  pressure  with  the  stethoscope  in  these  intercostal  spaces  over  the 
pulmonic  artery,  will  sometimes  develop  a  bellows  murmur  in  that 
vessel.  This  is  observed  in  young  persons  whose  costal  cartilages 
are  flexible.  The  murmur  is  due  to  pressure  on  the  artery,  as  in 
the  case  of  other  arteries,  more  accessible,  such  as  the  carotid,  iliac, 
femoral,  etc.  It  is  well  known  that  light  pressure  on  these  arteries 
frequently  develops  a  bellows  murmur. 

Inorganic  murmurs  occur  in  anaemic  persons,  and  the  palpable 
indications  of  anfemia  are  generally  manifest.  The  coexistence  of 
aneemia  is  a  point  to  be  considered  in  the  discrimination.  This 
condition,  it  is  true,  may  coexist  with  valvular  lesions,  and  contri- 
bute to  render  more  intense  and  diffused  the  murmurs  due  to  the 
latter.  Anasinia  alone  by  no  means  warrants  a  conclusion  that  a 
murmur  is  inorganic,  but,  added  to  other  evidence,  it  strengthens 
this  conclusion. 

Concurrent  bellows  murmurs  emanating  from  the  large  arterial 
trunks,  the  subclavian,  carotids,  etc.,  not  due  to  pressure  with  the 
stethoscope,  are  evidence  that  an  endocardial  murmur  is  inorganic. 
This  evidence  is  by  no  means  complete  in  itself,  but  adds  weight 
to  that  derived  from  other  sources.  A  continuous  murmur  or  hum 
produced  in  the  jugular  veins  is  very  frequently  associated  with  an 
endocardial  murmur  of  hasmic  origin.  This  venous  hum,  called, 
after  Bouillaud,  by  the  French  writers,  hruit  de  diable  (from  its 
resemblance  to  the  sound  of  the  humming-top,  which  is  known 
popularly  in  France  as  le  diaLIe),  has  heretofore  given  rise  to  con- 
siderable di.scussion  as  regards  its  source.  Laennec,  who  first 
observed  it,  referred  it  to  the  arteries.  In  this  he  has  been  followed 
by  most  French  writers.  Its  origin  in  the  veins  was  first  demon- 
strated by  Dr.  Ogier  Ward.  It  is  a  sufficient  demonstration  of  the 
correctness  of  the  latter  view  that  the  murmur  is  invariably  sus- 
pended by  interrupting  the  circulation  through  the  veins,  the 
arterial  circulation  continuing.  The  murmur  is  a  continuous 
humming  sound,  having  frequently  a  musical  intonation.  It  is 
best  heard  over  the  jugulars,  just  above  the  clavicles,  the  patient 
being  in  the  sitting  or  standing  posture.     It  is  highly  characteristic 


INORGANIC    MUKMURS.  205 

of  anosmia,  and  its  presence  in  conjunction  with  an  endocardial 
murmur  suspected  to  be  inorganic,  gives  strength  to  this  suspicion. 
Venous  hum  and  arterial  inorganic  murmurs  are  not  infrequently 
combined,' 

Inorganic  endocardial  murmurs  are  much  oftener  observed  in 
females  than  in  males,  a  fact  probably  due  to  the  greater  frequency 
of  antemia  in  the  former.  Sex,  therefore,  is  entitled  to  some  weight 
in  determining  whether  a  murmur  be  organic  or  inorganic. 

The  heart-sounds,  in  connection  with  inorganic  murmurs,  retain 
their  normal  intensity  and  characters,  or,  if  affected  at  all,  their 
intensity  is  augmented;  whereas,  in  connection  with  organic  mur- 
murs, they  often  present  abnormal  modifications,  which  are  to  be 
presently  considered. 

Finally,  organic  murmurs,  in  the  great  majority  of  the  cases  of 
chronic  disease,  when  these  first  come  under  the  cognizance  of  the 
physician,  are  associated  with  more  or  less  cardiac  enlargement. 
This  is  owing  to  the  fact  that  valvular  lesions  do  not,  as  a  rule, 
occasion  much  inconvenience  until  they  have  induced  enlargement 
of  the  heart.  A  murmur,  under  these  circumstances,  may  have 
existed  for  many  months  or  years,  and  escaped  observation  because 
the  patient  has  never  presented  himself  for  examination.  Coexist- 
ing enlargement,  then,  alone,  renders  it  altogether  probable  that  an 
endocardial  murmur  proceeds  from  organic  lesions.  It  is  true  that 
enlargement  of  the  heart,  uncomplicated  by  valvular  disease,  may 
be  associated  with  inorganic  murmurs,  but  it  is  evident  that  this 
coincidence  must  be  rare  when  it  is  considered  that  enlargement 
without  lesions  of  the  valves  is  by  no  means  frequent.  If,  in  con- 
nection with  cardiac  enlargement,  a  murmur  be  either  mitral  regur- 
gitant or  diastolic,  it  is  certainly  organic.  Doubt  can  only  arise 
when  the  murmur  is  an  aortic  direct  murmur.  On  the  other  hand, 
in  the  vast  majority  of  the  cases  in  which  a  murmur  is  inorganic, 
the  heart  is  not  enlarged,  a  fact  which  can  be  positively  determined 
by  means  of  physical  exploration. 

With  due  attention  to  the  several  points  which  have  been  briefly 
considered,  the  auscultator  need  not  be  at  a  loss,  in  most  instances, 
in  discriminating  with  positiveness  between  organic  and  inorganic 
endocardial  murmurs. 

'  Dr.  Walshe  remarks,  witli  reference  to  the  coexistence  of  an  endocardial  mur- 
mur and  venous  hum  :  "  I  do  not  remember  ever  to  have  observed  an  intra-cardiac 
spansemic  murmur  unattended  with  venous  hum."— 0?j  Diseases  of  the  Heart  and 
Lungs,  second  London  edition,  p,  242. 


206  PHYSICAL    SIGNS    OF    VALVULAE    LESIONS. 


Abnormal  Modifications  of  the  Heart-Sounds  in  Cases  op 
Valvular  Lesions. 

The  study  of  the  murmurs  has  so  much  engrossed  the  attention 
of  clinical  observers  of  late  years,  that  the  heart-sounds  have  not 
received  that  attention  which  their  importance  claims.  Abnormal 
modifications  of  the  heart-sounds  afford,  in  certain  cases,  as  has 
been  seen,  valuable  aid  in  the  localization  of  murmurs.  They  also 
serve  to  supply,  in  some  measure,  information,  which,  in  a  patho- 
logical point  of  view,  is  far  more  important  than  to  determine  the 
existence,  situation  and  character  of  lesions,  viz :  respecting  the 
amount  of  damage  which  the  valves  have  sustained.  The  im- 
portant practical  points  pertaining  to  these  two  objects  have  been 
already  incidentally  noticed,  but  it  will  not  be  amiss  to  recapitulate 
them  under  a  distinct  heading. 

The  results  of  the  clinical  study  of  the  heart-sounds  in  health, 
show  that  the  second  or  diastolic  sound,  consisting  solely  of  a  val- 
vular element,  is  in  fact  composed  of  an  aortic  sound  and  a  pul- 
monic sound,  which  are  generally  distinguishable  from  each  other 
when  the  stethoscope  is  applied  in  the  second  intercostal  space  near 
the  sternum  on  the  two  sides  successively,  the  aortic  second  sound 
being  heard  on  the  right,  and  the  pulmonic  second  sound,  on  the 
left  side.  The  first  sound  of  the  heart  differs  from  the  second,  in 
being  compounded  of  a  valvular  element  and  an  element  of  impul- 
sion. The  valvular  element,  however,  like  the  second  sound,  is 
composed  of  a  mitral  and  a  tricuspid  valvular  sound,  which  are 
distinguishable  from  each  other  when  auscultation  is  practised  suc- 
cessively in  different  situations.  For  further  details  the  reader  is 
referred  to  Chapter  first,  where  this  subject  is  fully  considered.* 

The  abnormal  modifications  of  the  first  sound  may  affect,  either 
separately  or  conjointly,  the  two  elements  into  which  this  sound 
is  resolvable,  and  the  two  subdivisions  of  the  valvular  element 
of  the  sound  ;  and  the  aortic  and  pulmonic  sounds  which  make  up 
the  second  sound  of  the  heart,  may  also  be  affected  singly  as  well 
as  combined.  It  is  in  connection  with  valvular  lesions  more  espe- 
cially, that  the  different  elements  and  their  subdivisions  are  liable 
to  be  modified  separately. 

^Mitral  lesions  impair  the  mitral  portion  of  the  valvular  element 
of  the  first  or  systolic  sound,  other  things  being  equal,  in  propor- 

'  Vide  page  58,  et  scq. 


HEAET-SOUNDS    IN    VALVULAR    LESIONS.  207 

tion  to  the  extent  of  injury  of  the  mitral  valve  which  the  lesions 
have  occasioned.  To  isolate  the  sound  referable  to  the  play  of  the 
mitral  valve,  the  stethoscope  is  to  be  placed  without  the  left  nipple 
at  a  distance  sufficiently  removed  to  eliminate  the  element  of  im- 
pulsion of  the  first  sound.  If  the  mitral  valvular  sound  be  abnor- 
mally feeble  or  wanting,  provided  the  heart  acts  with  sufficient 
vigor,  it  shows  considerable  or  great  imperfection  in  the  action  of 
the  valve ;  and,  conversely,  if  the  sound  preserve  its  normal  inten- 
sity and  quality,  it  may  be  inferred  that^  notwithstanding  the  exist- 
ence of  lesions,  the  valve  is  not,  as  yet,  much  damaged.  A  mitral 
regurgitant  murmur,  or  a  mitral*  direct  murmur,  either  or  both, 
co-exist  in  both  cases;  in  the  former  case  the  murmur  or  murmurs 
may  be  feeble,  and  in  the  latter  intense,  the  intensity  of  the  mur- 
mur bearing  no  proportion  to  the  gravity  of  the  lesions.  In  cases 
in  which  the  mitral  valvular  sound  is  notably  impaired  or  extin- 
guished, owing  to  the  extent  of  injury  to  the  valve,  the  tricuspid 
valvular  sound  may  generally  be  distinguished  by  applying  the 
stethoscope  at  or  a  little  without  the  inferior  or  right  border  of  the 
heart.  Mitral  regurgitation,  in  fact,  leads  to  augmented  intensity 
of  the  tricuspid  sound  by  inducing  hypertrophy  of  the  right  ventri- 
cle in  the  manner  already  described. 

Mitral  lesions  involving  obstruction  or  regurgitation,  more  espe- 
cially the  former,  lead  to  diminished  intensity  of  the  aortic  second 
sound,  and  an  augmented  intensity  of  the  pulmonic  second  sound. 
The  former  is  due  to  the  column  of  blood  propelled  through  the 
aorta  by  the  ventricular  contraction,  being  lessened  either  by  the 
deduction  of  the  quantity  of  blood  which  regurgitates,  or  by  the 
deficient  supply  from  the  auricle  to  the  ventricle.  The  latter  pro- 
ceeds from  hypertrophy  of  the  right  ventricle.  Both  effiscts  combine 
to  render  intensification  or  reinforcement  of  the  pulmonic  second 
sound,  a  valuable  sign  of  mitral  obstruction  or  regurgitation,  as  was 
first  pointed  out  by  Prof.  Skoda. 

In  connection  with  the  presence  of  a  diastolic  murmur,  the  nor- 
mal intensity  and  quality  of  the  aortic  second  sound  constitute 
evidence  that  the  murmur  has  its  source  at  the  mitral  orifice.  On 
the  other  hand,  if,  in  connection  with  a  diastolic  murmur,  the  aortic 
second  sound  is  notably  impaired  or  extinguished,  this  goes  to  show 
that  the  murmur  emanates  from  the  aortic  orifice. 

Aortic  lesions  affect  the  aortic  second  sound,  other  things  being 
equal,  in  proportion  to  the  extent  of  injury  of  the  valve  of  the  aorta. 
If  the  play  of  this  valve  be  defective,  the  sound  loses  more  or  less 


208  PHYSICAL    SIGXS    OF    VALVULAR    LESIOXS. 

of  its  normal  intensity.  The  sound  is  extinguished  when  the  valve 
is  rendered  useless  or  destroyed  by  disease.  Instances  of  extinction 
of  the  aortic  second  sound  are  not  very  infrequent.  In  such  in- 
stances the  continuance  of  the  pulmonic  second  sound  shows  that 
the  loss  of  the  aortic  sound  is  not  due 'to  weakened  action  of  the 
heart.  An  aortic  direct  or  an  aortic  regurgitant  murmur,  or  both, 
are  present,  indicating  the  fact  of  aortic  disease,  but  the  intensity 
and  quality  of  the  murmurs  here,  as  in  mitral  lesions,  do  not  con- 
stitute any  criterion  of  the  amount  of  damage  to  the  valve.  The 
abnormal  modifications  of  aortic  sound,  however,  afford  definite 
information  with  respect  to  that  important  point.^ 

Purring  Tremor. — This  term  is  applied  to  a  sense  of  vibration  or 
thrill  felt  on  placing  the  fingers  or  the  hand  on  the  prascordia.  It 
is  synonymous  with  the  name  applied  to  it  by  Laennec,  viz :  fre- 
missement  cataire^  so  called  because  it  resembles  the  sensation  com- 
municated to  the  hand  by  the  purring  of  a  cat.  Bouillaud  compares 
it  to  the  sensation  felt  when  the  hand  is  applied  over  the  larynx  of 
a  person  singing.  These  comparisons  cause  it  to  be  easily  recog- 
nized when  met  with  for  the  first  time.  It  is  doubtless  due  to 
tremulous  movements  of  the  heart,  which  are  propagated  to  the 
portion  of  the  thoracic  walls  Avith  which  the  heart  is  in  contact. 

Well-marked  purring  tremor  may  be  considered  as  a  sign  de- 
noting valvular  lesions  associated  with  hypertrophic  enlargement 
of  the  left  ventricle.  If  it  occur  under  other  circumstances,  the 
instances  are  so  infrequent  that,  for  all  practical  purposes,  the  rule 
may  be  taken  as  invariable.  The  valvular  lesions  which  most 
frequently  give  rise  to  it,  are  those  of  the  mitral  orifice  permitting 
free  regurgitation.  A  regurgitant  current  driven  through  this 
orifice  with  an  abnormal  force  in  consequence  of  the  augmented 
muscular  power  of  the  ventricle,  appears  to  be  the  immediate 
cause  in  the  majority  of  instances.  It  accompanies  or  follows  the 
ventricular  systole,  and  is  therefore  synchronous  with  the  first  sound, 
the  apex-beat  and  the  pulse.  A  diastolic  tremor  must  be  exceed- 
ingly rare,  but  is  stated  by  some  clinical  observers  to  occur  occa- 
sionally. When  due  to  mitral  lesions,  the  tremor  is  felt  within  the 
superficial  cardiac  region  below  the  level  of  the  nipple.  It  may  be 
more  or  less  marked,  the  intensity  depending,  in  a  great  measure, 

'  For  a  fuller  consideration  of  this  subject  than  is  contained  in  this  work,  the 
reader  is  referred  to  the  essay,  by  the  writer,  contained  in  the  Transactions  of  the 
American  Medical  Association,  vol.  xi.  p.  805. 


DIAGNOSTIC    CHARACTERS    OF    VALVULAR    LESIONS.      209 

on  the  power  witli  which  the  left  ventricle  contracts.  It  may  be 
present  or  strongly  marked  when  the  action  of  the  heart  is  excited 
by  any  cause,  and  absent  or  comparatively  feeble  when  the  organ 
is  tranquil.  In  the  progress  of  disease,  it  diminishes  and  ceases  as 
the  heart  becomes  weakened.  Although  it  has  a  pathognomonic 
significance  when  present,  its  absence  is  in  nowise  evidence  against 
the  existence  of  organic  lesions,  for  it  is  wanting  in  a  large  propor- 
tion of  the  cases  in  which  lesions  exist. 

The  sign  does  not  belong  exclusively  to  mitral  lesions.  It  ac- 
companies, in  some  instances,  aortic  lesions  associated  with  hyper- 
trophy of  the  left  ventricle.  It  is  then  felt  nearer  the  base  of  the 
organ.  A  thrill  due  to  the  current  of  blood  in  the  aorta  is  some- 
times perceived  above  the  heart  in  the  second  intercostal  space  on 
the  right  side.  Vascular  thrill  in  the  large  arteries  which  approach 
the  surface,  is  sufiiciently  common  in  cases  of  anemia.  With  the 
aneurismal  thrill  all  observers  are  familiar. 

Cardiac  tremor  is  not  a  sign  of  much  practical  value  in  view  of 
the  fact  that  it  is  present  only  in  a  small  proportiou  of  cases  of  val- 
vular lesions,  and  since  other  physical  signs,  which  are  constant, 
are  readily  available  for  diagnosis.  It  is,  however,  of  sufficient 
interest  and  importance  to  be  kept  in  mind  in  exploring  the  chest 
for  the  physical  evidence  of  cardiac  disease. 

Purring  tremor  is  to  be  distinguished  from  the  tactile  fremitus 
incident  to  the  presence  of  solid  deposit  on  the  pericardial  surfaces. 
The  latter,  which  will  be  noticed  in  connection  with  pericarditis,  is 
always  accompanied  by  an  exocardial  murmur  or  friction  sound 
on  auscultation.  Purring  tremor,  on  the  other  hand,  is  almost  in- 
variably associated  with  one  or  more  endocardial  murmurs. 


Diagnostic  Characters  of  Lesions  affecting  the  Mitral,  Aortic, 
Tricuspid,  and  Pulmonic  Valves  or  Orifices. 

The  diagnosis  of  valvular  lesions  is  based  on  physical  signs, 
together  with  the  symptoms  and  pathological  effects.  These  have 
been  considered.  The  significance  and  diagnostic  value  of  the 
different  signs,  symptoms,  and  effects,  have  been  already  pointed 
out.  It  remains  to  group  together  the  more  important  of  the 
characters  which  pertain  to  the  different  lesions  respectively.  This 
will  be  done  as  concisely  as  possible,  the  object  being  to  present  a 
brief  summary  of  the  distinctive  features  belonging  to  each  of  the 
14 


210  PHYSICAL    SIGNS    OF    VALVULAR    LESIOXS. 

several  classes  of  lesions.  Lesions  affecting  the  different  valves  or 
orifices  will  now  be  taken  separately  as  points  of  departure,  viz., 
mitral,  aortic,  tricuspid,  and  pulmonic  lesions.  These  will  be  con- 
sidered under  distinct  beads.  The  signs,  symptoms,  and  effects  of 
tricuspid  and  pulmonic  lesions  have  thus  far  been  passed  by,  owing 
to  the  comparative  infrequency  of  their  occurrence,  exclusive  of 
congenital  malformations,  and  in  order  not  to  render  the  subject 
needlessly  complicated  to  the  student.  It  will  suffice  to  present 
briefly  the  characters  which  belong  to  these  lesions  in  this  division 
of  the  subject.  As  involved  in  congenital  malformations,  they  will 
be  referred  to  hereafter. 


Diagnostic  Characters  of  Mitral  Lesions. 

Physical  Signs. — An  endocardial  systolic  murmur  is  present  in 
the  vast  majority  of  cases,  with  the  traits  which  distinguish  a 
mitral  regurgitant  murmur,  viz.,  its  maximum  of  intensity  at  or 
near  the  apex  of  the  heart,  the  intensity  diminishing  as  the  steth- 
oscope is  carried  upwards  over  the  body  of  the  heart ;  generally 
feeble  or  lost  above  the  base  of  the  organ ;  not  propagated  into  the 
carotids ;  often  diffused  over  the  left  lateral  surface  of  the  chest,  and 
not  infrequently  heard  on  the  posterior  surface,  at  the  lower  angle 
of  the  scapula,  and  in  the  interscapular  space  below  the  level  of  the 
spinous  ridge  of  the  scapula;  the  murmur  more  or  less  intense; 
generally  soft,  but  sometimes  rough. 

The  mitral  portion  of  the  valvular  element  of  the  first  sound  of 
the  heart  is  often  more  or  less  impaired,  or  extinguished,  the  tricus- 
pid portion  of  the  same  element  remaining  distinct,  or  abnormally 
intense.  The  aortic  second  sound  is  weakened ;  the  pulmonic 
second  sound  is  often  intensified.  Enlargement  of  the  heart  exists 
in  the  majority  of  the  cases  which  come  under  observation.  These 
signs  characterize  mitral  valvular  lesions  involving  insufficiency  or 
regurgitation  through  the  mitral  orifice,  i.  e.,  mitral  regurgitant 
lesions. 

A  diastolic  or  pre-systolic  murmur  is  present  in  a  small  propor- 
tion of  cases ;  generally  accompanied  by  a  systolic  mitral  regurgi- 
tant murmur,  but  it  may  be  present  without  the  latter;  its  intensity 
greatest  near  the  apex.  Weakened  aortic  second  sound  and  in- 
tensified pulmonic  second  sound  are  usually  present,  together  with 
cardiac  enlargement.     These  signs  characterize,  in  general,  contrac- 


DIAGNOSTIC    CHARACTERS    OF    MITRAL    LESIONS.       211 

tion  of  the  mitral  orifice  or  mitral  obstructive  lesions.  This  variety 
of  mitral  lesions,  however,  is  often  unattended  by  a  diastolic  mur- 
mur ;  so  that  absence  of  this  murmur  is  not  evidence  against  the 
existence  of  the  lesions. 

The  signs  distinctive  of  mitral  regurgitant  and  of  mitral  obstruc- 
tive lesions  are  combined  when  these  two  varieties  of  mitral  lesions 
coexist.     Purring  thrill  is  observed  in  a  certain  proportion  of  cases. 

Symptoms  and  Pathological  Effects. — Pain  is  rarely  present.  Ab- 
normal force  of  the  heart's  action  and  palpitation  denote  consecutive 
enlargement,  but  these  symptoms  are  often  not  prominent.  The 
pulse  is  small  and  weak  in  proportion  to  the  amount  of  obstruction 
or  regurgitation ;  in  an  advanced  stage,  it  becomes  irregular  and 
intermitting;  irregularity  of  the  pulse  is,  in  some  measure,  cha- 
racteristic of  obstructive  lesions.  It  is  sometimes  quick  or 
vibratory.  Turgescence  of  the  jugular  and  other  veins  and  dropsy 
occur  at  an  advanced  period  when  dilatation  of  the  right  cavities 
of  the  heart  has  been  induced.  Dyspnoea  is  more  or  less  marked 
in  proportion  to  the  amount  of  regurgitation  or  obstruction,  being 
more  marked  in  cases  of  obstructive  than  regurgitant  lesions. 
Cough  and  muco-serous  expectoration  occur  frequently.  Hcemop- 
tysis  is  of  frequent  occurrence,  and  extravasation  of  blood  in  the 
lungs,  or  pulmonary  apoplexy,  takes  place  occasionally.  CEdema 
of  the  lungs  is  a  common  event.  All  the  symptoms  and  effects 
referable  to  the  respiratory  system  are  more  marked  when  the 
lesions  are  obstructive  than  when  they  are  only  regurgitant. 

In  certain  cases,  lesions  involving  considerable  and  even  great 
regurgitation  or  obstruction  are  remarkably  latent  and  obscure  as 
regards  the  symptoms  and  pathological  effects.  The  diagnosis  in 
these,  as,  in  fact,  in  all  cases,  must  rest  mainly  on  the  physical 
signs.  On  the  other  hand,  lesions  may  exist,  the  existence  and 
seat  of  which  are  determinable  by  physical  signs,  without  involving 
much  regurgitation  or  obstruction,  and,  consequently,  not  giving 
rise  to  symptoms  or  pathological  effects.  These  lesions,  so  far  as 
immediate  danger  is  concerned,  may  be  considered  as  innocuous. 


Diagnostic  Characters  of  Aortic  Lesions. 

Physical  Signs. — An  endocardial  systolic  murmur  is  present  in 
the  vast  majority  of  cases,  with  the  traits  which  distinguish  an 


212  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

aortic  direct  murmur ;  viz.,  its  maximum  of  intensity  at  the  base 
of  the  heart;  the  intensity  diminishing  as  the  stethoscope  is  carried 
downward  over  the  body  of  the  heart;  comparatively  feeble  and 
often  lost  at  the  apex;  propagated  upward  in  the  direction  of  the 
aorta,  and  often  into  the  carotids ;  not  diffused  over  the  left  lateral 
surface  of  the  chest;  and  if  heard  on  the  posterior  surface,  either 
limited  to,  or  most  intense  in,  the  interscapular  space  on  and  above 
the  level  of  the  -spinous  ridge  of  the  scapula.  The  murmur  more 
or  less  intense;  generally  soft,  but  sometimes  rough,  and  occasion- 
ally musical.  This  murmur,  when  soft,  is  to  be  discriminated  from 
inorganic  aortic  murmurs. 

The  aortic  second  sound  of  the  heart  is  often  weakened  and 
indistinct;  the  pulmonic  second  sound  is  much  less  frequently 
intensified  than  in  cases  of  mitral  lesions.  The  mitral  and  tricuspid 
portions  of  the  valvular  element  of  the  first  sound  retain  their 
normal  intensity,  provided  the  lesions  are  limited  to  the  aortic  ori- 
fice. Enlargement  of  the  heart  exists  in  the  majority  of  cases 
which  come  under  observation.  These  signs  characterize  lesions 
■with  obstruction  at  the  aortic  orifice,  i.  e.,  obstructive  aortic  lesions. 

A  diastolic  murmur  is  present  in  a  small  proportion  of  cases,  but 
in  a  larger  ratio  than  in  cases  of  mitral  lesions ;  it  is  generally 
accompanied  by  a  systolic  aortic  direct  murmur,  but  it  may  be  pre- 
sent without  the  latter ;  its  intensity  is  greatest  near  the  left  margin 
of  the  sternum,  on  or  about  the  level  of  the  fourth  rib.  The  aortic 
second  sound  is  impaired  in  proportion  as  the  valve  is  injured.  The 
pulmonic  second  sound  is  less  frequently  intensified  than  in  cases 
of  mitral  lesions.  Cardiac  enlargement  is  usually  present.  These 
signs  characterize  insufficiency  of  the  aortic  valve,  or  aortic  regur- 
gitant lesions. 

The  signs  distinctive  of  aortic  obstructive  and  aortic  regurgitant 
lesions  are  combined  when  these  two  varieties  of  aortic  lesions  co- 
exist. Purring  thrill  is  observed  more  infrequently  than  in  cases 
of  mitral  lesions. 

Symptoms  and  Pathological  Effects. — Pain  is  oftener  present  than 
in  cases  of  mitral  lesions,  but  is  often  absent.  Abnormal  force  of 
the  heart's  action  and  palpitation,  as  a  rule,  are  more  prominent 
symptoms  than  in  cases  of  mitral  lesions.  The  pulse,  in  cases  of  con- 
siderable obstruction,  is  not  notably  reduced  in  size  and  strength ;  it 
is  rarely  irregular  or  intermitting,  and  still  more  rarely  unequal.  In 
cases  of  regurgitation  it  is  quick,  jerking,  collapsing,  and  a  longer 


DIAGNOSTIC    CHARACTERS    OF    TRICUSPID    LESIONS.      213 

interval  than  natural  is  sometimes  observed  between  the  apex-beat 
or  systolic  sound  and  the  pulsation  in  remote  arteries.  Visible 
pulsation  of  superficial  arteries  is  frequently  marked.  Turgescence 
of  the  jugular  and  other  veins,  and  dropsy,  occur  at  a  later  period 
than  in  cases  of  mitral  lesions,  and  are  oftener  wanting.  Dyspnoea 
is  less  marked  than  in  obstructive  or  regurgitant  lesions  of  equal 
amount  affecting  the  mitral  valve  and  orifice.  Cough  and  muco- 
serous  expectoration  and  haemoptysis  are  comparatively  infrequent. 
Pulmonary  apoplexy  very  rarely,  if  ever,  occurs  as  a  pathological 
effect.  Q5dema  of  the  lungs  is  less  frequent.  All  the  symptoms 
and  effects,  in  fact,  referable  to  the  respiratory  system,  are  less  fre- 
quent and  marked  than  in  cases  of  mitral  regurgitant,  and  still  less 
than  in  mitral  obstructive  lesions. 

Lesions  affecting  the  aortic  as  well  as  the  mitral  valve  or  orifice, 
and  involving  considerable  obstruction  or  regurgitation,  are  in  cer- 
tain cases  remarkably  latent  and  obscure  as  regards  the  symptoms 
and  pathological  effects.  The  diagnosis  rests  mainly  on  the  physi- 
cal signs.  Aortic  lesions,  also,  may  exist,  and  give  rise  to  physical 
signs,  without  involving  much  or  any  obstruction  or  regurgitation, 
and  are  therefore  innocuous  as  regards  immediate  danger. 

The  obstructive  and  regurgitant  varieties  of  mitral  and  aortic 
lesions  are  found  in  various  combinations  in  different  cases.  The 
diagnosis  is  then  based  on  the  union  of  the  characters  distinctive 
of  the  varieties  severally.  The  physical  signs  characteristic  of 
each  variety  can  generally  be  distinguished  in  these  combinations. 


Diagnostic  Characters  of  Tricuspid  Lesions. 

Physical  Signs. — A  systolic  regurgitant  murmur  referable  to  the 
tricuspid  orifice  is  rare  even  among  the  cases  in  which  regurgitation 
through  this  orifice  takes  place.  Regurgitation  in  consequence  of 
widening  of  the  tricuspid  orifice,  without  a  corresponding  increase 
of  the  size  of  the  valve,  is  not  an  uncommon  result  of  enlargement 
of  the  right  side  of  the  heart  consequent  on  mitral  obstruction  or 
regurgitation.  The  regurgitant  current,  however,  rarely  gives  rise 
to  a  murmur,  probably  because  the  muscular  power  of  the  right 
ventricle  is  not  sufficient  to  propel  the  current  with  force  enough 
to  produce  audible  vibrations.  For  the  same  reason  a  murmur  is 
not  always  present  in  the  exceedingly  few  instances  of  tricuspid 
regurgitation  occurring  in  consequence  of  organic  changes  analo- 


214  PHYSICAL    SIGNS    OF    VALVULAR   LESIONS. 

gous  to  those  which  affect  the  mitral  valve.  The  rule,  then,  which 
is  applicable  to  mitral  lesions,  viz.,  that  a  murmur  is  present  in  the 
vast  majority  of  cases,  cannot  be  applied  to  tricuspid  lesions;  and, 
hence,  absence  of  murmur  is  not  proof  that  the  latter  do  not  exist. 
A  tricuspid  regurgitant  murmur,  however,  is  sometimes  observed. 
It  is  rarely,  if  ever,  intense  or  rough,  and  is  usually  low  in  pitch. 
Its  maximum  of  intensity  is  said  to  be  at  or  above  the  xiphoid 
cartilage.  It  is  heard  within  circumscribed  limits,  and  is  feeble  or 
lost  over  the  apex  of  the  heart.  In  two  instances  of  tricuspid 
lesions  not  associated  with  lesions  affecting  the  left  side  of  the 
heart,  which  have  come  under  my  observation,  a  soft  and  feeble 
systolic  murmur  was  limited  to  the  superticial  cardiac  region. 
Since  tricuspid  lesions,  not  congenital,  are  in  most  instances  asso- 
ciated with  lesions  of  one  or  more  of  the  valves  of  the  left  side  of 
the  heart,  a  tricuspid  regurgitant  murmur,  when  present,  accom- 
panies a  murmur,  or  murmurs,  referable  to  the  mitral  or  aortic 
orifice,  or  to  both  these  orifices.  It  is  to  be  distinguished  from  the 
latter  by  difference  in  pitch  and  quality,  in  addition  to  the  differ- 
ence of  situation  at  which  its  maximum  of  intensity  is  observed. 

Tricuspid  regurgitation  must  diminish  ,the  intensity  of  the  pul- 
monic second  sound.  If  the  tricuspid  valve  be  injured,  the  tricuspid 
portion  of  the  valvular  element  of  the  first  sound  must  also  be  im- 
paired. 

A  diastolic  murmur  may  .originate  at  the  tricuspid  orifice.  Ex- 
amples, however,  of  this  murmur  are  among  the  rarest  of  the  rare 
curiosities  of  medical  experience,  not  only  because  contraction  of 
this  orifice  is  exceedingly  infrequent,  but  also  because  the  muscular 
power  of  the  right  auricle  is  insufficient  to  give  rise  to  murmur  in 
most  of  the  instances  in  which  the  orifice  is  contracted.  This  mur- 
mur, theoretically,  should  be  expected  to  be  best  heard  at  or  just 
above  the  xiphoid  cartilage. 

Tricuspid  obstructive  lesions  must  diminish  the  intensity  of  the 
pulmonic  second  sound  of  the  heart. 

The  combination  of  a  systolic  tricuspid  regurgitant  and  a  diastolic 
tricuspid  direct  murmur  is  possible.  Dr.  Walshe  gives  an  example, 
based,  however,  on  clinical  evidence  without  the  confirmation  of  a 
post-mortem  examination.' 

Free  regurgitation  through  the  tricuspid  orifice,  with  great  dila- 
tation of  the  right  auricle  and  hypertrophy  of  the  right  ventricle, 

'  Diseases  of  tlie  Lungs  caiid  Heart,  2d  London  edition,  p.  G94. 


DIAGNOSTIC    CHAEACTEPvS    OF    PULMONIC    LESIONS.      215 

may  occasion  a  strong  impulse  felt  at  the  base  of  the  heart,  to  the 
right  of  the  sternum,  simulating  aneurism.  An  example  contained 
in  the  late  work  by  Dr.  Stokes  is  referred  to  in  Chapter  I.^ 

SymjJtoms  and  Pathological  Effects. — Regurgitant  and  obstructive 
lesions,  situated  at  the  tricuspid  orifice,  do  not  produce  those  im- 
mediate effects  on  the  respiratory  system  and  the  pulse  which 
pertain  to  analogous  lesions  seated  at  the  mitral  orifice.  They  do 
not  tend  directly  to  give  rise  to  dyspnoea,  heemoptysis,  extravasa- 
tion, etc.,  which  are  dependent  on  pulmonary  congestion.  They 
do  not  occasion  irregularity,  inequality,  weakness,  etc.,  of  the  pulse. 
Their  immediate  effects  are  manifested  in  the  systemic  venous 
system.  Congestion  of  the  systemic  veins  is  a  direct  result  pro- 
portionate to  the  degree  of  obstruction  or  regurgitation.  Symp- 
toms denoting  this  result  are  turgescence  of  the  jugular  and  other 
veins ;  undulation  and  venous  pulsation  produced  by  the  contrac- 
tion of  the  right  ventricle,  and,  in  some  instances,  by  the  auricular 
contraction ;  lividity  due  to  accumulation  in  the  venous  radicles. 
A  pathological  effect  of  the  congestion  of  the  systemic  veins  is 
general  dropsy.  This  jffe^t  occurs  more  directly  and  at  a  much 
earlier  period  when  tricuspid  lesions  exist,  than  when  it  depends 
on  dilatation  of  the  right  cavities  consequent  on  valvular  lesions 
situated  at  the  left  side  of  the  heart.  Cerebral  apoplexy  is  more 
likely  to  be  dependent  on  tricuspid  than  on  mitral  or  aortic  lesions, 
exclusive  of  the  instances  in  which  this  affection  proceeds  from 
fibrinous  plugs  detached  from  within  the  heart-cavities. 


Diagnostic  Characters  or  Pulmonic  Lesions. 

Physical  Signs. — Lesions  situated  at  the  pulmonic  orifice  may 
give  rise  to  a  murmur  with  the  first  sound  of  the  heart,  which,  fol- 
lowing the  plan  pursued  in  naming  the  mitral  and  aortic  murmurs, 
should  be  called  a  pulmonic  direct  murmur.  This  murmur  has  its 
maximum  of  intensity  in  the  second  or  third  intercostal  spaces  on 
the  left  side  of  the  sternum,  the  situation  where  the  pulmonic 
second  sound  of  the  heart  is  isolated  from  the  aortic  second  sound. 
It  may  be  propagated  thence  for  a  certain  distance  in  a  direction 
towards  the  left  clavicle,  but  not  in  the  direction  of  the  aorta,  and 
not  heard  over  the  carotids.     To  be  considered  as  evidence  of 

'  Vide  page  54. 


216  PHYSICAL    SIGNS    OF    VALVULAR    LESIONS. 

pulmonic  lesions,  not  only  must  the  murmur  be  referable  to  the 
pulmonic  orifice,  but  it  must  be  evidently  an  organic  murmur. 
Attention  to  the  several  points  already  considered,  will  enable  the 
auscultator  to  determine  that  it  is  not  inorganic.  It  has  already 
been  stated  that  pressure  over  the  pulmonary  artery  in  young 
subjects,  with  the  stethoscope,  will  sometimes  develop  a  murmur  in 
this  vessel.  Pressure  from  some  cause  within  the  chest  may  also 
cause  a  murmur  referable  to  this  artery.  It  has  been  observed  in 
cases  in  which  the  pressure  on  the  vessel  was  produced  by  an 
aneurismal  tumor,  a  morbid  deposit  within  the  pericardium,  en« 
larged  bronchial  glands,  and  a  solidified  portion  of  lung.^  It  must 
be  difficult,  in  some  instances,  to  eliminate  these  several  sources  of 
fallacy.  A  pulmonic  murmur  may  be  quite  intense,  I  have  met 
with  an  example  of  a  musical  murmur,  systolic  and  diastolic,  per- 
sisting through  the  whole  beat,  in  other  words,  continuous,  dis- 
tinctly referable  to  the  pulmonic  artery,  and  so  loud  as  to  be  heard 
with  the  ear  in  close  proximity  to,  but  not  in  contact  with  the 
walls  of  the  chest.^ 

A  diastolic  murmur  may  accompany  insufficiency  of  the  pulmonic 
valve,  constituting  a  pulmonic  regurgitant  murmur.  It  must  be 
difficult  to  distinguish  between  this  and  an  aortic  regurgitant  mur- 
mur, except  it  be  accompanied  by  a  pulmonic  direct  murmur,  and 
not  by  an  aortic  direct  murmur.  In  the  vast  majority  of  the  cases 
in  which  a  diastolic  murmur  is  present,  it  is  either  an  aortic  regur- 
gitant, or  a  mitral  direct  murmur. 

Lesions  involving  injury  to  the  pulmonic  valve  must  impair  the 
intensity  and  distinctness  of  the  pulmonic  second  sound  of  the  heart. 

A  pulmonic  direct  and  a  pulmonic  regurgitant  murmur  may  be 
associated  in  the  same  case,  or  either  may  be  present  without  the 
other.  Pulmonic  lesions,  however,  exclusive  of  congenital  mal- 
formations, are  so  rare,  that  the  opportunities  of  any  clinical  ob- 
server, however  large  his  experience,  for  studying  the  physical 
signs  are  extremely  limited.  Hypertrophy  of  the  right  ventricle, 
which  is  produced  by  obstructive  or  regurgitant  lesions  of  the 
pulmonic  orifice,  involves  augmented  intensity  of  the  tricuspid 
valvular  element  of  the  first  sound,  and  an  impulse  in  the  epigas- 
trium. 

'  Bellingliam,  op.  cit.,part  ii.  p.  38C.  Da  Costa  in  Am.  Jouni.  of  Med.  Sciences, 
January,  1859. 

2  Case  of  Kelly,  Private  Records,  vol.  x.  p.  Lu7. 


TREATMENT    OF    VALVULAR    LESIONS.  217 

SymiJtoms  and  Pathological  Effects. — The  primary  effect  of  ob- 
structive or  regurgitant  lesions  situated  at  the  pulmonic  orifice  is 
enlargement  of  the  right  ventricle.  The  secondary  and  remote 
effects,  and  the  symptoms  thereon  dependent,  are  essentially  those 
whicli  are  occasioned  by  tricuspid  lesions,  being  due  to  distension 
of  the  right  auricle,  tricuspid  regurgitation,  and  congestion  of  the 
systemic  veins. 


Treatment  op  Lesions  affecting  the  Yalves  and  Orifices  of  the 

Heart. 

With  reference  to  the  management  of  patients  affected  with 
chronic  valvular  lesions,  several  important  considerations,  which 
have  been  already  presented,  are  to  be  kept  in  mind. 

1.  The  anatomical  changes  which  the  valves  and  orifices  have 
undergone  are  irremediable,  and  therefore  do  not  claim  any  spe- 
cial medicinal  treatment.  The  existing  lesions  must  remain.  The 
damage  which  they  have  occasioned  cannot  be  repaired.  Medi- 
cation employed  for  that  object  will  be  worse  than  useless.  The 
morbid  processes  giving  rise  to  the  lesions,  have  occurred  long 
before  the  symptoms  of  an  organic  affection  of  the  heart  became 
developed.  In  the  majority  of  cases  the  origin  of  the  affection  may 
be  dated  at  an  attack  of  acute  rheumatism  several  years  prior  to  the 
period  when  ailments  referable  to  the  heart  are  first  experienced. 
The  changes  incidental  to  these  processes  have,  in  the  mean  time, 
been  slowly  progressive.  They  will,  in  all  probability,  continue 
to  progress,  involving  more  and  more  damage.  This  we  cannot 
expect  to  prevent,  but  something  can  be  done  to  retard  their  pro- 
gress, and,  more  especially,  to  control  their  primary  effects. 

These  facts  not  being  always  sufficiently  appreciated,  practitioners 
sometimes  employ  mercury  and  other  remedies  called  alteratives, 
with  a  view  to  the  removal  of  morbid  material  deposited  on  or 
about  the  valves.  I  have  met  with  cases  in  which  depletion,  low 
diet,  counter-irritation,  etc.,  were  resorted  to,  under  the  idea  that 
the  lesions  involved  persisting  chronic  inflammation  of  the  endo- 
cardial membrane.  These  measures  can  hardly  fail  to  aggravate 
the  cardiac  symptoms,  and  to  expedite  effects  which  it  is  a  great 
object  of  the  management  to  postpone  as  long  as  possible. 

2.  Lesions  may  exist,  giving  rise  to  murmurs  more  or  less  in- 
tense, without  producing  any  immediate  morbid  effects,  not  involv- 


218  TREATMENT    OF    VALVULAR    LESIONS, 

ing  either  obstruction  or  regurgitation.  Such  lesions  may  remain 
for  an  indefinite  time  innocuous,  but  there  is  a  liability  of  the 
changes  incidental  to  them  leading,  at  some  future  period,  to  serious 
results.  These  cases,  therefore,  claim  a  certain  amount  of  watchful- 
ness and  supervision.  The  existence  of  a  cardiac  murmur  depend- 
ent on  innocuous  lesions  is  often  ascertained  by  accident,  there  being 
no  symptoms  of  disease  referable  to  the  heart.  I  have  repeatedly 
met  with  it  in  examining  persons  who  considered  themselves  in 
perfect  health.  These  persons  are  in  no  immediate  danger,  and  it 
would  give  rise  to  needless  alarm  to  inform  them  that  they  have 
an  organic  affection  of  the  heart,  since  it  is  a  common  notion  that 
any  such  affection  involves  liability  to  sudden  death.  There  is, 
however  a  prospective  danger  not  to  be  overlooked.  It  has  oc- 
curred to  me  in  two  instances  to  examine  for  life  insurance  persons 
presenting  an  organic  murmur,  without  other  evidence  of  cardiac 
or  other  disease,  who  were,  of  course,  not  deemed  proper  subjects 
for  insurance;  but  they  succeeded  in  obtaining  policies  in  other 
companies,  and  both  have  since  died  with  well-marked  disease  of 
the  heart. 

3.  Even  when  lesions  exist  which  do  involve  more  or  less  ob- 
struction or  regurgitation,  it  does  by  no  means  follow  that  the 
immediate  danger  is  great.  This  statement  holds  good  in  some 
cases  in  which  there  is,  at  the  same  time,  considerable  enlargement 
of  the  heart.  I  am  acquainted  with  several  persons  who  do  not 
consider  themselves  as  invalids,  some  being  engaged  in  active  busi- 
ness, in  whom  the  existence  of  organic  murmur,  with  cardiac  en- 
largement, was  ascertained  many  years  ago.'  In  such  cases  the 
organic  affection  does  not  call  for  active  therapeutical  measures, 
but  knowledge  of  the  existence  of  the  cardiac  affection  is  highly 
important  to  the  practitioner,  and  should  influence  his  advice  as 
regards  habits,  regimen,  etc.,  as  well  as  his  treatment  of  intercur- 
rent diseases.  The  tolerance  of  lesions  in  some  instances  is  truly 
remarkable.  A  boy,  aged  eleven  years,  who  recently  came  under 
my  observation,  presenting  three  organic  murmurs,  viz.,  a  mitral 
regurgitant,  an  aortic  direct,  and  an  aortic  regurgitant,  with  much 
cardiac  enlargement,  the  praecordia  projecting  and.  the  apex  beating 
half  an  inch  without  the  nipple,  not  only  made  no  complaint  of 
symptoms  referable  to  the  heart,  but  was  able  to  take  violent  exer- 

'  Vide  Essay  on  Clinical  Study  of  Heart-Sounds,  Trans.  Am.  Med.  Association, 
vol,  xi. 


TREATMENT    OF    VALVULAR    LESIOXS.  219 

cise,  and  to  engage  in  rough  sports  with  apparently  as  much  ease 
as  any  of  his  companions.  In  this  as  in  other  instances  in  which 
lesions  involving  more  or  less  obstruction  or  regurgitation  are  borne 
without  notable  inconvenience,  the  physical  signs  denoted  enlarge- 
ment by  hypertrophy,  not  by  dilatation,  and  the  action  of  the  heart 
was  vigorous.^ 

4.  The  enlargement  of  the  heart  being,  as  a  rule,  proportionate 
to  the  amount  of  obstruction  or  regurgitation,  or  both,  occasioned 
by  valvular  lesions,  the  abnormal  size  of  the  heart  may,  in  general, 
be  taken  as  a  criterion  of  the  importance  to  be  attached  to  the 
lesions.  So  long  as  the  heart  is  not  much  enlarged,  the  patient  is 
exposed  to  only  certain  contingent  evils  incident  to  the  lesions — 
for  example,  arterial  obstruction  from  detached  deposits.  Exclusive 
of  accidental  events  and  associated  affections,  the  symptoms  and 
remote  effects  of  obstructive  and  regurgitant  lesions  correspond  to 
the  primary  effects  of  these  lesions,  as  denoted  by  the  increased 
bulk  of  the  heart.  This  statement  holds  good  in  the  majority  of 
cases,  but,  as  already  stated,  the  rule  is  not  without  exceptions. 

5.  The  secondary  and  remote  effects  of  valvular  lesions,  as  a  rule, 
are  not  developed  so  long  as  the  enlargement  of  the  heart  is  by 
hypertrophy,  unless,  from  some  cause,  weakness  of  the  organ  has 
been  induced.  Obstructive  and  regurgitant  lesions  tend  first  to 
produce  hypertrophy.  The  muscular  walls  increase  in  thickness 
up  to  a  certain  limit.  When  this  limit  is  reached,  dilatation  of  the 
cavities  ensues,  and,  finally,  predominates  over  the  hypertrophy. 
The  increased  power  of  the  organ,  incident  to  the  hypertrophy, 
compensates  for  the  immediate  consequences  of  obstruction  and 
regurgitation.  The  hypertrophy  is,  in  fact,  a  conservative  pro- 
vision to  obviate  the  evils  of  obstructive  and  regurgitant  lesions. 
The  patient  is  comparatively  safe  while  hypertrophy  predominates. 
The  secondary  and  remote  effects  are  incident  to  the  dilatation 
which  takes  place  after  the  hypertrophy  has  reached  its  limit.  The 
immediate  danger,  other  things  being  equal,  is  proportionate  to  the 
amount  of  predominance  of  the  dilatation.  This  is  because  the 
heart  is  weakened  in  proportion  to  the  predominance  of  dilatation. 
Weakness  of  the  organ,  due  to  other  causes  than  dilatation,  will 
also  favor  the  development  of  the  secondary  and  remote  effects  of 
valvular  lesions.  These  facts  are  of  great  importance  in  their 
bearing  on  the  treatment  of  patients  affected  with  these  lesions. 

'  Case  of  Horan,  New  Orleans  Charity  Hospital.     H.  Reports,  vol.  xiii.  p.  84. 


220  TREATMENT    OF    VALVULAR    LESIONS. 

In  view  of  the  foregoing  considerations,  the  main  objects  of 
treatment  which  rehate  directly  to  the  condition  of  the  heart,  in  the 
early  stage  of  valvular  lesions,  are,  1st.  To  prevent,  or,  as  far  as 
possible,  to  retard  the  progressive  anatomical  changes  incident  to 
the  existing  lesions ;  and,  2d.  To  obviate  the  tendency  to  weakness 
and  dilatation  of  the  heart. 

The  anatomical  changes  seated  in  the  valves  and  orifices,  give 
rise  to  the  varied  morbid  appearances  which  have  been  mentioned* 
in  Chapter  third.  These  changes  cannot  be  reached  by  any  special 
remedies.  Their  progress  can  only  be  indirectly  affected  by  pre- 
venting overstraining  of  the  valves,  which  must  occur  whenever  the 
organ  is  unduly  excited  or  overtasked,  and  by  avoiding  the  causes 
which  favor  renewal  of  inflammation  of  the  endocardium.  Exces- 
sive muscular  exercise,  great  mental  excitement,  the  intemperate 
use  of  alcoholic  stimulants,  etc.,  promote  the  progress  of  valvular 
lesions,  by  exciting  unduly  and  overtasking  the  heart.  Patients 
with  valvular  lesions  devoid  of  immediate  danger,  should  pursue  a 
course  of  life  which,  as  far  as  practicable,  will  be  exempt  from  causes 
inducing  great  disturbance  of  the  circulation.  In  pointing  out  the 
regimen,  habits,  etc.,  however,  the  importance  of  fostering  the  mus- 
cular power  of  the  heart,  to  which  reference  will  be  presently  made, 
is  not  to  be  lost  sight  of.  The  causes  favoring  the  development  of 
endocarditis,  are,  in  general,  those  which  tend  to  give  rise  to  rheu- 
matism, since  in  the  vast  majority  of  cases  endocardial  inflammation 
is  of  rheumatic  origin.  Unusual  exposure  to  the  vicissitudes  of  the 
weather  are  regarded,  perhaps  justly,  as  often  determining  an 
attack  of  rheumatism  when  the  diathesis  exists.  The  existence  of 
the  diathesis  is  shown  by  the  previous  occurrence  of  one  or  more 
rheumatic  attacks  in  the  majority  of  the  persons  affected  with  val- 
vular lesions,  the  origin  of  the  latter  being  referable,  in  such  cases, 
to  a  former  attack  of  rheumatism.  A  fresh  attack  exposing  the 
patient  to  a  renewal  of  the  endocarditis,  is  a  calamity  to  be  averted, 
if  possible,  by  avoiding  the  exciting  causes  so  far  as  these  are 
appreciable.  In  fulfilling  this  object  of  treatment,  hygienic  regula- 
tions are  chiefly  involved.  Judicious  management  will  undoubtedly 
do  something  toward  rendering  the  progress  of  the  lesions  more 
slow  than  would  otherwise  be  the  case ;  but  we  can  hardly  expect 
to  arrest  their  progress.  If,  however,  they  are  very  slowly  pro- 
gressive, life  and  comfortable  health  may  be  prolonged  for  an 
indefinite  period,  perhaps  even  to  an  advanced  stage. 

'   Vide  page  120. 


TREATMENT    OF    VALVULAR    LESIONS-  221 

The  same  hygienic  regulations  are  equally  important  with  refer- 
ence to  the  second  object,  viz.,  to  obviate  the  tendency  to  weakness 
and  dilatation  of  the  heart.  The  judicious  management  of  patients 
affected  with  valvular  lesions  prior  to  the  development  of  the 
secondary  and  remote  effects  of  these  lesions,  depends  in  a  great 
measure,  on  a  proper  appreciation  of  this  object.  It  is  commonly 
said  by  writers  on  diseases  of  the  heart,  that  the  treatment  of  val- 
vular lesions  virtually  resolves  itself  into  that  designed  to  prevent 
and  diminish  enlargement  of  the  heart.  This  involves  an  important 
error  as  well  as  an  important  truth.  It  is  highly  desirable  to  pre- 
vent dilatation  but  not  to  arrest  hypertrophy.  On  the  contrary,  if 
enlargement  must  occur  as  a  result  of  obstructive  or  regurgitant 
lesions,  h3^pertrophy  is  to  be  encouraged,  if  by  so  doing,  dilatation 
may  be  prevented.  The  serious  evils  of  valvular  lesions,  as  we 
have  seen,  occur  when  the  limit  of  hypertrophy  has  been  reached 
and  dilatation  predominates.  In  the  predominance  of  hypertrophy 
may  be  said  to  consist,  in  a  great  measure,  the  security  of  the 
patient.  This  remark  is  also  applicable  to  the  muscular  power  of 
the  heart.  So  long  as  the  organ  acts  with  vigor,  the  secondary  and 
remote  evils  are  deferred.  Weakness  of  the  heart  leads  to  these 
evils.  Weakness  predisposes  to  dilatation,  and,  conversely,  dilata- 
tion involves  weakness.  To  prevent  weakness  and  dilatation,  then, 
in  the  early  stage  of  valvular  lesions,  is  the  great  object  of  treat- 
ment so  far  as  it  relates  directly  to  the  condition  of  the  heart. 

Undue  excitement  and  overtasking  of  the  heart  induce  weakness 
and  favor  dilatation.  The  muscular  power  here,  as  in  other  situa- 
tions, is  exhausted  by  too  great  exertion,  and  the  walls  yield  more 
readily  to  distension,  under  these  circumstances,  from  the  accumu- 
lation of  blood  within  the  cavities.  The  causes,  already  referred  to, 
which  excite  unduly  and  overtask  the  heart,  viz.,  excessive  muscu- 
lar exercise,  mental  excitement,  the  intemperate  use  of  alcoholic 
stimulants,  etc.,  are,  therefore,  to  be  avoided  with  respect  to  the 
second,  not  less  than  the  first  object  of  treatment.  Exercise, 
however,  within  certain  limits,  is  highly  important  with  a  view  to 
the  preservation  of  the  power  of  the  heart's  action.  Patients 
aflfected  with  obstructive  or  regurgitant  lesions  will  retain  a  com- 
pensatory vigor  of  the  heart,  and  the  epoch  when  dilatation 
succeeds  hypertrophy  will  be  postponed  for  a  longer  period  by 
habits  which  involve  a  judicious  amount  of  exercise  than  by  a  life 
of  complete  repose.  Active  occupations,  whether  pursued  as  a 
calling  or  for  amusement,  or  with  reference  merely  to  exercise. 


222  TREATMENT   OF    VALVULAR    LESIONS. 

should  not.  be  abandoned.  Persons  under  the  necessity  of  perform- 
ing daily  manual  labor  will  do  better  to  continue  to  work,  so  far  as 
they  are  able  without  inconvenience,  than  to  become  fixtures  in 
the  wards  of  a  hospital.  They  who  are  above  this  necessity  should 
either  follow  some  active  pursuits  or  engage  in  sports  which 
demand  a  certain  amount  of  physical  activity.  Indolence  or 
inaction  of  the  muscular  system  tends  to  produce  weakness  of  the 
heart  and  favors  fotty  degeneration,  thereby  contributing  to  the 
production  of  dilatation  rather  than  hypertrophy.  The  rules 
which  should  govern  exercise  have  already  been  considered  in 
connection  with  the  treatment  of  hypertrophy,  to  which  the  reader 
is  referred.*  These  rules  are  applicable  to  cases  of  valvular  lesions, 
with  or  without  hypertrophy.  They  are,  of  course,  not  to  the 
same  extent  applicable  to  cases  in  which  the  lesions  have  already 
led  to  dilatation. 

The  diet  suited  to  obviate  a  tendenc}''  to  weakness  and  dilatation 
is  that  best  adapted  to  healthy  nutrition.  Healthy  nutrition,  and 
thereby  the  muscular  vigor  of  the  heart,  require  blood  rich  in 
nutritive  materials.  A  poor  arid  insufficient  diet  tends  to  hasten 
the  evils  resulting  from  valvular  lesions.  The  diet  should  embrace 
a  fair  proportion  of  animal  food.  Liquids  should  be  taken  sparingly, 
the  object  being  to  secure  a  good  quality,  but  not  to  increase  the 
quantity  of  blood.  Eestrictions,  as  respects  fatty  substances  and 
those  readily  converted  into  fat,  are  important  if  there  are  grounds 
to  suspect  a  disposition  to  fatty  degeneration.  The  articles  of  food 
should  be  adapted  to  the  digestive  powers.  The  action  of  the 
heart,  as  is  well  known,  is  liable  to  be  disturbed  through  its  sym- 
pathetic connection  with  the  stomach,  when  digestion  is  labored  or 
imperfect.  Dyspeptic  disorders  will  claim  appropriate  treatment. 
Tonics  and  stimulants,  in  moderate  quantity,  are  indicated  when- 
ever the  digestive  powers  are  enfeebled.  Exercise  in  the  open  air, 
within  proper  limits,  is  important  with  reference  to  its  influence  on 
digestion.  Cheerfulness  and  mental  recreation  are  desirable  for  the 
same  end. 

Opposite  conditions  of  the  blood  alike  tend  to  weakness  and 
dilatation,  viz.,  plethora  and  ancemia.  If  the  blood  be  too  abund- 
ant and  the  red  globules  in  excess,  the  heart  is  overtasked  and 
unduly  stimulated.  Bloodletting,  under  these  circumstances,  may 
be  appropriate.     But  it  should  be  employed  with  discrimination 

'  Chap.  L  page  72. 


TREATMENT    OF    VALVULAR    LESIONS.  223 

and  great  circumspection,  inasmuch  as  the  impoverishment  caused 
by  its  injudicious  employment  is  a  condition  worse  than  plethora. 
In  general,  other  methods  of  depletion,  which  are  not  spoliative, 
are  to  be  preferred,  viz.,  saline  laxatives  and  diuretics,  in  conjunc- 
tion with  a  dry  diet.  Anaemia  is  a  far  more  unfavorable  condition 
than  plethora,  and  claims  efficient  treatment  with  chalybeate  tonics, 
nutritious  diet,  etc.  The  symptoms  referable  to  the  heart,  in  some 
cases  of  valvular  lesions,  are,  in  a  great  measure,  due  to  functional 
disorder  incident  to  ansemia,  and  when  the  antemic  condition  is 
removed,  all  the  symptoms  may  disappear.  This  fact  should  be 
borne  in  mind.  The  practitioner  is  liable  to  consider  all  the 
symptoms  as  resulting  directly  and  exclusively  from  the  lesions, 
and,  consequently,  is  led  to  exaggerate  the  immediate  danger  from 
the  latter.  Patients  who  suffer  much  from  palpitation,  etc.,  when 
ansemia  is  conjoined  with  valvular  lesions,  may  experience  no 
inconvenience  when  the  blood  'is  restored  to  its  normal  condition. 
This  is  intelligible  in  view  of  the  well-known  fact  that  anasmia 
often  gives  rise  to  functional  disorder  of  the  heart  when  this  organ 
is  free  from  organic  disease. 

The  treatment  of  valvular  lesions,  as  thus  far  considered,  has 
reference  to  the  condition  of  the  heart  prior  to  the  period  when 
dilatation  has  ensued,  either  enlargement  of  the  organ  not  having 
taken  place,  or  hypertrophy  being  as  yet  predominant.  The 
secondary  and  remote  effects  of  valvular  lesions,  as  has  been  seen, 
for  the  most  part  occur  after  dilatation  predominates  over  hyper- 
trophy. It  remains  to  notice  the  treatment  due  to  the  condition  of 
the  heart  at  this  stage,  and  the  treatment  of  the  secondar}'  and 
remote  effects. 

So  far  as  the  heart  is  concerned,  the  treatment  at  this  stage  is 
essentially  that  which  has  been  already  considered  in  connection 
with  the  subject  of  dilatation.^  Extrinsic  circumstances  affecting 
the  circulation,  such  as  exercise,  mental  emotions,  etc.,  now  occa- 
sion symptoms  of  disturbance  much  more  marked,  and  attended 
with  far  greater  inconvenience.  The  ability  to  take  exercise  with- 
out palpitation  and  dyspncea  is  diminished,  and  quietude  may  be 
indispensable.  Within  the  limits,  however,  to  which  exercise  may 
be  borne  without  discomfort,  it  is  still  desirable.  A  nutritious, 
sustaining  diet  is  not  less  indicated.  Attention  to  the  condition  of 
the  stomach  is  equally  important.     Bloodletting   is    much   more 

'  Vide  Chap.  I.  page  S5. 


22-i  TREATMENT    OF    VALVULAR   LESIONS. 

rarely,  if  indeed  it  be  ever,  called  for.  Plethora,  if  it  exist,  claims 
methods  of  depletion  which  are  not  spoliative.  Anaemia  demands 
the  same  efficient  measures.  The  general  object  is  to  increase,  if 
possible,  the  muscular  power  of  the  heart.  It  is  doubtful  whether 
this  object  is  promoted  by  any  remedies  which  exert  a  direct, 
special  effect  upon  the  heart.  Nax  vomica  or  strychnia,  given  in 
minute  doses  and  long  continued,  is,  however,  advocated  by  Dr. 
Corson  as  a  remedy  having  such  an  effect.' 

At  this  stage,  not  only  is  the  heart  enfeebled,  but  the  rhythm  of 
its  action  is  often  disturbed,  as  denoted  by  irregularity,  inter- 
mittency,  and  inequality  of  the  pulse.  Eemedies  designed  to 
tranquillize  and  regulate  the  movements  of  the  organ  are  now 
indicated.  For  this  end,  digitalis  often  proves  a  valuable  remedy. 
Care  is  to  be  taken  not  to  give  this  remedy  to  the  extent  of  retard- 
ing too  much  the  heart's  action.  Observing  proper  caution  in  this 
respect,  the  action  of  the  heart  ncTt  only  becomes  more  regular 
under  its  use,  but  the  contractions  of  the  ventricles  appear  to  take 
place  with  greater  power  and  completeness,  as  denoted  by  increased 
fulness  and  force  of  the  pulse.  It  is  proper  to  add  that  this  state- 
ment, as  regards  the  value  of  digitalis,  is  in  opposition  to  the  views 
of  some  distinguished  authors,  who  regard  it  as  rarely  useful  and 
attended  with  hazard.  Its  usefulness  and  freedom  from  danger 
turn  on  the  influence  which  it  exerts  on  the  power  of  the  heart's 
action.  The  opinion  which  I  have  expressed  is  based  on  inferences 
drawn  from  clinical  observations.  Belladonna,  the  hydrocyanic 
acid,  aconite,  and  sometimes  opium  in  small  doses,  are  other 
remedies  which  may  be  found  useful  in  fulfilling  this  indication. 

A  large  share  of  the  secondary  and  remote  effects  of  valvular 
lesions  are  dependent  on  congestion.  The  lungs  are  generally  first 
and  most  affected  ;  afterwards,  the  brain  and  abdominal  viscera. 
The  tendency  to  congestion  of  internal  organs  is  obviated  most 
effectively  by  measures  which  prevent  weakness  and  dilatation  of 
the  heart,  or  which  increase  its  muscular  power  if  these  primary 
effects  have  already  taken  place.  In  addition,  something  may  be 
effected  by  promoting,  as  far  as  possible,  the  circulation  in  the  ex- 
tremities and  at  the  surface  of  the  body,  and  by  revulsive  measures. 
The  body  should  be  protected  by  sufficiently  warm  clothing,  and 
prolonged  exposure  to  cold  should  be  avoided.  Friction  of  the 
surface  and  stimulating  pediluvia  are  useful  in  fulfilling  this  indi- 

'  New  York  Journal  of  Medicine,  May,  1855. 


TREATMENT    OF    VALVULAR    LESIONS.  225 

cation.     Rubefacient  applications  and  dry  cupping  are  the  appro- 
priate revulsives. 

Dyspnoea,  cough,  and  expectoration,  often  claim  special  attention. 
The  suffering  from  a  sense  of  breathlessness,  frequently  severe,  must 
be  palliated  by  the  remedies  known  as  antispasmodics,  particularly 
the  ethereal  preparations,  and  by  anodynes,  in  addition  to  revulsive 
measures.  Palliation,  in  most  instances,  is  all  that  can  be  expected 
from  treatment.  Cough,  exceeding  that  required  for  expectoration, 
may  be  allayed  by  such  remedies  as  h3^oscyamus,  conium,  hydro- 
cyanic acid,  or  by  small  doses  of  opium.  Muco-serous  expectora- 
tion is  sometimes  a  mode  of  relief,  being  a  sort  of  local,  spontaneous 
depletion,  and  is  to  be  encouraged  rather  than  arrested.  Super- 
induced or  intercurrent  pulmonary  affections,  such  as  bronchitis, 
pneumonia,  and  pleurisy,  demand  appropriate  treatment,  but 
bloodletting  and  other  measures  which  tend  to  weaken  the  heart, 
are  to  be  employed  with  great  circumspection.  The  coexistence 
of  valvular  lesions  and  dilatation  generally  renders  sustaining 
measures  more  than  ever  important  in  the  management  of  these 
affections. 

The  importance  of  correcting  disorders  of  digestion,  and  improv- 
ing this  function  when  impaired,  is  not  less  in  the  advanced  than 
in  the  early  stage  of  valvular  lesions.  Mercury  is  often  prescribed 
with  a  view  to  relieving  congestion  of  the  liver  by  increasing  the 
secretion  of  bile.  Granting  that  it  has  this  effect,  it  is  a  remedy  of 
doubtful  propriety  if  given  so  as  to  incur  risk  of  mercurialization. 
As  an  occasional  laxative,  or  cathartic,  it  is  admissible.  Constipa- 
tion is  to  be  avoided,  and  moderate  purgation,  from  time  to  time, 
affords  relief  as  a  means  of  local  depletion  when  the  digestive  organs 
are  suffering  from  congestion.  Purgatives  too  often  repeated,  how- 
ever, will  do  harm  by  depressing  the  vital  powers,  and  thereby 
weakening  the  heart. 

For  the  relief  of  cerebral  congestion,  which  we  have  seen  occa- 
sions inconvenience  and  evils  less  frequently  than  is  generally 
supposed,  reliance  must  be  had  on  the  revulsive  measures,  in  addi- 
tion to  those  which  relate  directly  to  the  condition  of  the  heart. 

General  dropsy  is  a  remote  effect  occurring  in  a  large  proportion 
of  the  cases  of  valvular  lesions  which  are  prolonged  to  an  advanced 
stage.  It  is  usually  evidence  of  a  degree  of  weakness  and  dilatation, 
precluding  expectation  of  permanent  improvement,  and  denoting 
that  a  fatal  termination  is  not  far  distant.  But  in  some  instances 
complete  relief  is  obtained,  and  the  dropsy  may  not  recur  for  a 
15 


226  TREATMENT    OF    VALVULAR   LESIONS. 

considerable  length  of  time.  These  are  instances  in  which  the 
dropsy  has  been  promoted  by  associated  morbid  conditions,  such 
as  an  ancemic  state  of  the  blood,  or  by  extrinsic  causes  which  have 
temporarily  enfeebled  the  heart.  The  event  is  not  only  important 
as  a  symptom,  but  it  imposes  inconvenience  and  suffering  proper 
to  itself,  and  hastens  a  fatal  issue.  It  calls,  therefore,  for  appro- 
priate treatment. 

The  immediate  objects  of  the  treatment  of  cardiac  dropsy  are  the 
resorption  of  the  effused  liquid,  and,  at  the  same  time,  increased 
power  and  completeness  of  the  ventricular  contractions.  Eesorp- 
tion  is  to  be  effected,  if  possible,  by  eliminating  water  from  the 
blood  by  means  of  diuretics  or  hydragogue  cathartics,  conjoined 
with  a  dry  diet.  In  the  selection  of  diuretics,  those  are  to  be  pre- 
ferred which  increase  the  quantity  of  urine  without  increasing,  pro- 
portion ably,  its  solid  constituents ;  in  other  words,  those  which 
eliminate  especially  water.  Experimental  observations  render  it 
probable  that  different  diuretics  differ  in  this  respect,  digitalis, 
juniper  and  squill,  for  example,  increasing  the  flow  of  urine,  while 
the  amount  of  solid  matter  is  below  that  of  health.'  It  is  as  im- 
portant in  the  treatment  of  dropsy  by  diuretics  not  to  eliminate 
solids,  as  the  latter  is  the  object  of  treatment  with  a  view  to  depura- 
tion in  various  affections.  In  the  employment  of  diuretics  and 
hydragogue  cathartics,  more  especially  the  latter,  great  care  is 
required  not  to  push  the  remedies  to  an  extent  to  lower  too  much 
the  powers  of  the  system,  and  thereby  weaken  the  action  of  the 
heart.  While  measures  are  pursued  to  effect  resorption,  the  second 
object  of  treatment  should  not  be  lost  sight  of,  viz  :  to  increase  the 
power  and  completeness  of  the  ventricular  contractions.  This 
object  involves  nutritious  diet,  tonics  and  exercise  within  proper 
limits. 

The  choice  between  diuretics  and  h}'dragogue  cathartics  will  de- 
pend on  the  readiness  and  extent  to  which  the  kidneys  respond  to 
the  former  of  these  two  classes  of  remedies.  Different  cases  differ 
much  in  this  respect.  In  some  instances  hypersecretion  of  urine  is 
easily  effected;  in  other  instances  with  difficulty,  and  not  to  the 
extent  desired.  Reliance  must  then  be  had  on  cathartics.  In  gene- 
ral, diuretics  should  be  first  tried,  and  they  are  to  be  preferred  if 

'  On  the  Action  of  Certain  Vegetable  Diuretics.  By  William  A.  Hammond, 
M.  D.,  assistant  surgeon  U.  S.  Army,  Am.  Journ.  of  Med.  Sciences,  No.  for  Jan., 
1859.  This  is  an  interesting  and  important  subject  for  further  experimental 
observations. 


TEEATMENT    OF    VALVULAR    LESIONS.  227 

found  to  operate  satisfactorily.  The  general  principle  involved  in 
the  selection  of  diuretics  has  been  stated,  but  we  have  not,  as  yet, 
sufficient  facts  to  establish  a  division  of  all  the  numerous  articles 
which  induce  diuresis  into  those  which  do  and  those  which  do  not 
increase  the  solid  constituents  of  the  urine.  As  regards  the  diuretic 
effect,  we  have  to  be  guided,  in  a  great  measure,  by  experimental 
trials  in  individual  cases.  A  diuretic  remedy  may  act  efficiently  in 
one  case  and  prove  inefficient  in  another  case,  a  different  article 
being  found  to  act  satisfactorily  in  the  latter.  All  practical  phy- 
sicians must  have  been  led  to  notice  this  fact.  Usually,  different 
diuretics  act  better  in  combination  than  separately.  Digitalis  and 
squill,  for  example,  may  be  given  in  combination,  and,  at  the  same 
time,  the  bitartrate,  the  nitrate,  or  the  acetate  of  potash,  largely 
diluted  in  an  infusion  of  juniper,  parsley,  or  fieabane.  As  remarked 
by  Prof.  Wood,  diuretics  may  fail  at  a  particular  period,  and  act 
efficiently  at  another  period  in  the  same  case.  The  ingestion  of 
liquids  should  be  restricted  so  far  as  due  regard  to  comfort  will 
permit.  The  mode  by  which  diuretics  lead  to  resorption  being  the 
elimination  of  water  from  the  blood,  which  involves  an  increase  of 
the  density  of  the  latter,  it  is  plain  that  their  efficacy  in  relieving 
dropsy  will  be  limited  or  rendered  nugatory  by  the  free  introduc- 
tion of  liquid  into  the  system. 

Prof.  Christison  has  advocated  the  external  use  of  diuretics  in 
certain  cases.  I  have  repeatedly  tried  this  method,  and  generally 
without  much  success.  In  one  instance,  however,  which  came 
under  my  observation,  the  patient  being  under  the  care  of  my 
friend,  Prof.  J.  P.  White,  the  effect  was  remarkable.  Diuretics 
given  internally  having  lost  their  effect  in  this  case,  a  liniment 
composed  of  equal  parts  of  the  tinctures  of  squill,  digitalis,  and 
iodine,  and  two  parts  of  soap  liniment,  was  applied  freely,  with 
considerable  friction,  over  the  abdomen  and  thighs.  The  patient 
took  no  remedy  in  addition  except  the  iodide  of  iron.  Under  this 
treatment,  in  a  week,  he  lost  nine  pounds  in  weight,  the  secretion 
of  urine  being  greatly  increased.  The  anasarca  disappeared,  and 
did  not  again  return  for  several  months,  the  comfort  and  general 
health  of  the  patient  becoming  in  the  mean  time  much  improved. 

Hydragogue  cathartics  are  to  be  employed  when  diuretics  fail  to 
act  satisfactorily  or  to  accomplish  the  end  desired.  Of  the  different 
articles  embraced  in  this  variety  of  cathartic  remedies,  elaterium  is 
the  most  efficient.  The  great  activity  of  this  article,  when  pure, 
requires  care  in  its  administration.    From  a  sixth  to  a  quarter  of  a 


228  TREATMENT    OF    VALVULAR    LESIONS. 

grain  may  be  directed  every  one  or  two  hours  till  a  sufficient  num- 
ber of  watery  stools  are  procured.  The  intervals  between  the  days 
of  its  administration  must  be  regulated  by  the  state  of  the  patient 
and  the  prostration  occasioned  by  its  operation.  The  bitartrate  of 
potash,  given  in  pretty  large  doses  in  a  concentrated  solution,  fre- 
quently acts  efficiently.  This  remedy  and  jalap  form  an  efficient 
combination. 

The  treatment  of  cardiac  dropsy  is  sometimes  remarkably  suc- 
cessful. The  effused  liquid  is  rapidly  and  completely  absorbed. 
The  patient  experiences  so  much  relief  that  he  is  encouraged  to 
hope  for  recovery.  This  the  physician  does  not  expect,  but  he 
may  hope  to  postpone  the  recurrence  of  dropsy  by  strengthening 
the  heart  and  removing  causes  which  exist  in  addition  to  the  ob- 
struction due  to  the  cardiac  affection.  Ansemia  predisposes  power- 
fully to  dropsical  effusion.  The  restoration  of  the  blood  to  its 
normal  condition  ma}'  secure  long  exemption  from  recurrence  of 
the  dropsy.  If,  however,  the  dropsy  be  altogether  dependent  on 
the  obstruction  caused  by  the  cardiac  affection,  some  degree  of  pal- 
liation is  all  that  is  to  be  hoped  for.  The  accumulation  of  effused 
liquid  remains  and  augments,  often,  notwithstanding  appropriate 
measures  of  treatment.  This  is  more  likely  to  be  the  case  if  the 
patient  be  obliged  to  remain  much  of  the  time  in  the  sitting  pos- 
ture on  account  of  dyspnoea.  The  coexistence  of  Bright's  disease 
also  lessens  greatly  the  prospect  of  relief,  but  this  combination,  as 
has  been  seen,  is  less  frequent  than  is  generally  supposed.  Tem- 
porary relief  is  sometimes  obtained  by  puncturing  the  lower  extre- 
mities, water  draining  away  in  abundance  through  the  artificial 
openings.  Numerous  minute  punctures  may  be  made  with  a  fine 
needle,  not  deep  or  large  enough  to  occasion  either  pain  or  hemor- 
rhage. These  may  be  frequently  repeated.  I  have  not  observed 
unpleasant  results  from  this  mode  of  making  punctures.  If  the 
size  of  the  punctures  be  sufficient  to  cause  visible  wounds,  there  is 
a  liability  to  erysipelatous  inflammation  and  gangrene,  which  ren- 
ders the  operation  of  doubtful  expediency.  This  remark  is  also 
applicable  to  incisions,  which  some  writers  have  advised.  The 
great  distension  of  the  integument  of  the  lower  extremities  in  some 
instances  gives  rise  to  fissures  and  ulcerations,  through  which  the 
effused  liquid  freely  escapes.  When  these  occur,  it  is  not  wise  to 
attempt  to  heal  them  promptly. 

An  important  part  of  the  management  of  cases  of  valvular  lesions 
relates  to  the  communications  on  the  subject  to  be  made  to  the  pa- 


TREATMENT    OF    VALVULAR    LESIONS.  229 

tlent.  An  endocardial  organic  murmur  which  is  discovered  inci- 
dentally in  the  examination  of  a  patient,  need  not  be  announced, 
for,  if  the  heart  be  not  enlarged,  the  danger  is  prospective,  perhaps 
remote,  and  gratuitous  uneasiness  may  be  occasioned  by  the  patient 
being  made  acquainted  with  the  existence  of  an  organic  affection. 
Unsoundness  of  the  heart  is  generally  supposed  to  be,  in  all  cases, 
a  very  serious  matter,  and  to  involve  liability,  at  any  moment,  to 
sudden  death.  Some  practitioners,  participating  in  this  popular 
impression,  injudiciously  apprise  patients  that  they  must  expect  to 
be  taken  oft*  without  warning.  I  have  met  repeatedly  with  instances 
in  which  persons  have  been  so  informed,  much  to  the  prejudice  of 
their  comfort,  usefulness,  and  even  their  prospect  of  preserving 
comfortable  health  for  a  long  period.  It  should  be  borne  in  mind 
that  lesions  which  give  rise  to  murmurs  are  often  innocuous,  the 
danger  being  prospective,  and  perhaps  remote.  And  even  when 
the  lesions  are  of  a  nature  to  involve  obstruction  or  regurgita- 
tion, and  have  led  to  considerable  enlargement  of  the  heart,  life 
and  comfortable  health  may  be  preserved  for  many  years.  More- 
over, statistics  show  that  sudden  death  occurs  in  only  a  small  pro- 
portion of  the  cases  of  organic  disease  of  the  heart,  often  involving, 
when  it  does  occur,  some  associated  morbid  condition — for  instance, 
structural  degeneration  of  the  cerebral  arteries,  leading  to  rupture 
and  extravasation.  Cases  of  fatal  apoplexy  occurring  in  persons 
with  cardiac  lesions  are  frequently  incorrectly  explained  by  im- 
puting the  occurrence  wholly  to  the  condition  of  the  heart. 

If  the  attention  of  the  physician  be  called  by  the  patient  to  the 
state  of  the  heart,  and  an  opinion  requested,  the  existence  of  lesions 
cannot  be  denied.  Truth,  and  justice  to  the  physician  himself,  as 
well  as  good  faith  toward  the  patient,  require  that  the  fact  should 
be  candidly  stated.  The  statement  then  should  be  accompanied  by 
such  explanations  as  will  serve  to  divest  the  fact  of  greater  import- 
ance than  really  belongs  to  it.  If  proper  pains  be  taken,  this,  hap- 
pily, is  not  difficult,  since  the  mental  condition  incident  to  disease 
of  the  heart  generally  leads  patients  to  accept  the  most  favorable 
view  of  the  case  which  can  be  conscientiously  submitted. 

The  prognosis,  to  the  friends  of  the  patient,  should  be  cautiously 
given.  The  duration  of  life,  except  in  cases  of  advanced  disease, 
is  extremely  variable.  There  is,  on  the  one  hand,  a  liability  to 
certain  accidents  and  incidental  affections  which  may  prove  fatal 
unexpectedly;  and,  on  the  other  hand,  patients  often  live  for  a  long 
time  after  the  signs  and  symptoms  denote  lesions  of  a  most  serious 
character. 


CHAPTER   V. 

CONGENITAL   MISPLACEMENTS,   DEFECTS,   AND 
MALFORMATIONS   OF  THE  HEART. 

Transpositions  and  expositions — Ectopia  peetoralis  cordis — Ectopia  cordis  ventralis — Ec- 
topia cordis  eephalica — Deiicieney  of  the  pericardium — Biloculate  heart — Heart  with 
three  cavities — Deficiency  of  auricular  and  ventricular  septa — Obliteration  of,  and 
obstruction  at,  the  pulmonic  artery — Supernumerary  septum — Patency  of  the  foramen 
ovale  and  the  ductus  arteriosus — Deficiency  and  excess  of  segments  of  semilunar  valves 
— Union  of  curtains  of  the  mitral  and  tricuspid  valves — Diagnosis  of  malformations — 
Causes  of  death — Coexistence  of  tuberculosis — Treatment. 

Cyanosis.  Definition — Its  connection  with  different  malformations — Conclusions  respect- 
ing the  mode  of  its  production — Cyanotic  phenomena  in  various  affections  exclusive  of 
malformation  of  the  heart — Diversities  as  respects  degree  and  extent  of  the  cyanotic 
discoloration — Other  variations — Associated  symptoms — Diagnosis — Prognosis — Treat- 
ment. 

The  various  malformations,  etc.,  of  the  heart  are  especially  in- 
teresting in  their  relations  to  the  physiology  of  the  circulation  and 
to  embryology.  A  general  knowledge  of  this  subject,  however,  is 
important  to  the  physician.  It  is  desirable  for  the  practitioner  to 
recognize  the  existence  of  congenital  affections,  by  means  of  signs 
and  symptoms,  during  life,  and,  as  far  as  practicable,  to  discriminate 
between  them.  The  study  of  these  affections  has  an  important 
bearing  on  a  subject  which  will,  in  consequence,  be  considered  in 
this  chapter,  viz.,  cyanosis. 

Treating  of  the  different  varieties  of  congenital  affections  only 
so  far  as  is  consistent  with  the  practical  scope  of  this  work,  they 
will  occupy  but  a  small  space.  I  shall  follow  the  philosophical 
arrangement  adopted  in  the  late  treatise  by  Dr.  Peacock,  to  which 
the  reader  desirous  of  a  fuller  consideration  of  the  subject  is  re- 
ferred.^ The  facts  relating  to  tliis  subject  which  will  be  presented 
are  derived  mainly  from  the  author  just  named. 

■  Ou  Malformatlonf?,  etc.,  of  the  Human  Heart.  With  Original  Cases.  By  Tho- 
mas B.  Peacock,  M.  D.,  Fellow  of  the  Royal  College  of  Physicians,  etc.  London: 
John  Churchill,  1858. 


CONGENITAL    MISPLACEMENTS.  231 


CONaENITAL    MISPLACEMENTS    OF    THE    HEART. 


The  misplacements  are  either  of  transposition  or  exposition.  In- 
stances in  which  the  heart  is  situated  in  the  right  side  of  the  chest, 
are  not  so  infrequent  but  that  numerous  examples  have  been 
reported.  In  some  instances  the  other  viscera  are  likewise  trans- 
posed, and  in  other  cases  the  situation  of  the  heart  alone  is  abnor- 
mal. This  abnormity  is  not  incompatible  with  health  and  long  life. 
Removal  of  the  heart  into  the  right  side,  as  is  well  known,  occurs 
as  a  result  of  pleurisy,  wii,h  a  large  amount  of  effusion,  affecting 
the  left  side.  The  organ  may  form  attachments  and  remain  fixed 
in  the  right  side  after  the  liquid  effusion  has  been  absorbed.  A 
similar  result  sometimes  follows  absorption  of  a  large  amount  of 
liquid  effusion  into  the  right  pleural  sac.  The  existence  of  pleuritic 
effusion  is  readily  ascertained  by  means  of  the  physical  signs,  and 
the  permanent  changes  in  the  size  and  configuration  of  the  affected 
side  enable  the  diagnostician  to  determine  the  fact  of  its  previous 
existence.  In  either  case  the  misplacement  of  the  heart  is  not  to 
be  considered  as  congenital. 

In  cases  of  exposition,  the  heart  may  be  situated  exterior  to  the 
chest.  These  instances  constitute  the  variety  known  as  ectopia  pec- 
toralis  cordis.  In  none  of  the  instances  cited  by  Dr.  Peacock  in 
which  the  heart  alone  was  exterior  to  the  chest,  did  life  continue 
over  forty  hours  after  birth.  This  variety  of  ectopia  is  extremely 
rare,  excluding  the  cases  in  which,  at  the  same  time,  the  viscera 
of  the  abdomen  are  protruded.  They  offer  valuable  opportunities 
for  studying  the  movements  of  the  heart  by  means  of  the  sight  and 
touch.  In  another  variety  of  exposition,  the  heart  is  situated 
below  the  diaphragm,  and  in  these  cases  there  may  or  may  not  be 
an  external  tumor.  This  variety,  called  ectopia  cordis  ventralis,  is 
not  incompatible  with  long  life  and  vigorous  health.  In  another 
curious  variety,  the  heart  is  situated  in  the  front  of  the  neck.  This 
is  called  ectopia  cordis  cephalica.  In  all  the  cases  reported  of  this 
variety,  the  infants  have  died  shortly  after  birth.  These  different 
misplacements  may  be  readily  ascertained  by  inspection,  palpation 
and  auscultation.  But  in  cases  of  ectopia  cordis  ventralis,  the  mal- 
position may  occasion  so  little  inconvenience  that  attention  may 


232      CONGENITAL    MISPLACEMENTS,  ETC.   OF    THE    HEART. 

not  have  been  directed  to  it  during  life,  and  the  anomaly,  therefore, 
is  not  ascertained  before  death. 


DEFICIENCY    OF    THE    PERICARDIUM. 


In  some  of  the  cases  reported  by  the  older  anatomists  as  examples 
of  congenital  absence  of  the  pericardium,  it  is  probable  that  there 
existed  pericardial  adhesions,  and  the  deficiency  was  only  apparent, 
not  real.  But  the  pericardium  is  undoubtedly  sometimes  wanting. 
Dr.  Baillie  described  an  instance  which  came  under  his  observa- 
tion incidentally,  the  chest  having  been  opened  to  explain  to  a  class 
of  students  the  normal  situation  of  the  thoracic  viscera.  The  heart 
was  bare,  lying  loose  in  the  left  cavity  of  the  pleura.  In  this 
instance  there  had  been  no  morbid  symptoms  referable  to  the  heart 
during  life.  In  several  other  examples  cited  by  Dr.  Peacock,  no 
troubles  pertaining  to  the  heart  or  circulation  had  existed.  In  one 
instance  the  patient  died  at  the  age  of  seventy-five  years  with 
disease  of  the  aortic  valve.  There  are  no  diagnostic  characters 
by  which  the  existence  of  this  abnormity  can  be  determined  during 
life. 


MALFORMATIONS   OF   THE   HEART. 


The  malformations  of  the  heart  are  dependent,  for  the  most  part, 
on  arrest  of  development  at  different  periods  of  foetal  life.  Ex- 
amples of  the  biloculate  heart,  i.  e.,  the  heart  consisting  of  a  single 
auricle  and  ventricle,  are  rare,  but  a  considerable  number  of 
authentic  cases  have  been  reported  by  different  observers.  This 
abnormity  is  compatible  with  only  a  short  duration  of  life,  death 
occurring,  in  general,  a  few  hours  or  days  after  birth.  The  pul- 
monic vessels  in  these  cases  are  given  off  by  the  aorta,  the  venae 
cavae  and  pulmonic  veins  terminating  in  the  single  auricle.  In 
this  variety  of  malformation,  the  arrest  of  development  takes  place 
early  in  foetal  life.  Cases  in  which  the  heart  consists  of  only  three 
chambers  are  not  so  rare  as  the  preceding.  They  denote  an  arrest 
of  development  occurring  at  a  later  period  of  intra-uterine  exist- 


MALFORMATIONS.  233 

ence.  Persons  with  this  malformation  have  lived  for  several  years, 
but  generally  death  takes  place  within  a  few  weeks  or  months. 
The  cavities  are  two  auricles  and  a  single  ventricle,  the  latter 
presenting  sometimes  a  rudimentary  septum.  These  cases  differ 
as  respects  the  arrangement  of  the  primary  vessels.  In  some  cases, 
both  the  aorta  and  the  pulmonic  artery  spring  from  the  single 
ventricle;  in  others,  the  aorta  gives  origin  to  the  pulmonary 
vessels,  or,  if  the  pulmonic  artery  exist,  it  is  in  a  rudimentary 
form,  and  the  blood  is  supplied  to  the  lungs  through  the  ductus 
arteriosus.  Deficiency  of  the  ventricular  and  auricular  septa,  either 
or  both,  is  a  variety  of  malformation  vastly  more  common  than  the 
two  varieties  just  noticed.  When  the  ventricular  septum  is  more 
or  less  deficient,  the  imperfection  generally,  but  not  invariably, 
exists  at  the  base.  The  explanation  of  this  is,  the  division  of  the 
cavities  is  here  effected  last  during  foetal  life.  Hence,  this  form  of 
malformation  indicates  an  arrest  of  development  occurring  at  a 
period  still  later  than  in  the  two  previous  forms.  In  the  fully 
developed  organ  there  exists  at  the  upper  part  of  the  septum  a 
triangular  space  in  which  the  ventricular  chambers  are  only  sepa- 
rated by  the  endocardium  and  fibrous  tissue  on  the  left  side, 
together  with  the  lining  membrane  and  a  thin  layer  of  muscular 
tissue  on  the  right  side.  The  average  length  of  the  sides  of  this 
triangle  is  about  seven  lines,  and  the  base  is  somewhat  wider. 
This  is  sometimes  distinguished  as  the  undefended  space.  It  has 
been  a  question  with  pathologists  whether,  in  a  certain  proportion 
of  the  instances  of  deficiency  at  this  portion  of  the  interventricular 
septum,  it  be  not  due  to  rupture  or  perforation  after  birth.  Bouil- 
laud  contends  that  it  is  frequently  attributable  to  disease.  Dr. 
Peacock  concurs  in  the  opinion  that  it  is  thus  attributable  in  some 
cases,  but  he  thinks  that  the  proportion  is  smaller  than  that 
claimed  by  the  French  pathologist  just  named.  Deficiencies  in 
both  the  ventricular  and  auricular  septa  are  usually  associated  with 
other  defects,  and  especially  with  obstruction  at  the  pulmonic 
orifice.  The  former  are  probably  due,  in  a  great  measure,  to  the 
latter.  The  effect  of  pulmonic  obstruction  on  the  blood-currents 
prevents  that  complete  separation  of  the  cavities  (exclusive  of  the 
foramen  ovale)  which  should  take  place  during  the  latter  part  of 
foetal  life.  Considerable  deficiency  of  the  partitions  between  the 
ventricles  or  auricles  is  not  uniformly  attended  by  marked  symp- 
toms referable  to  the  heart.  Persons  may  present  few  or  no 
indications  of  the  existence  of  any  heart  affection.    If  the  deficiency 


234      COXGENITAL    MISPLACEMENTS,  ETC.   OF    THE    HEART. 

in  the  septa  be  associated  with  mal -arrangement  of  the  primary  ves- 
sels, the  consequences  are  far  more  serious.  The  pulmonic  artery,  as 
well  as  the  aorta,  may  spring  from  the  left  ventricle.  Virtually,  in 
such  cases,  the  heart  consists  of  three  cavities.  The  left  ventricle 
becomes  greatly  enlarged,  and  the  right  ventricle  proportionately 
atrophied.  Life  has  continued  for  years  under  these  circumstances- 
In  other  cases,  the  aorta,  as  well  as  the  pulmonic  artery,  arises 
from  the  right  ventricle.  The  pulmonic  orifice  in  these  cases  is 
usually  obstructed ;  the  foramen  ovale  remains  open,  and  the 
ductus  arteriosus  occasionally  continues  pervious. 

Obliteration  of  the  pulmonic  artery  would  at  first  seem  to  be  an 
abnormity  incompatible  with  life.  Several  cases,  however,  have 
been  reported  in  which  death  did  not  occur  for  several  years.  In 
connection  with  this  malformation,  the  interventricular  septum  is 
often  defective.  The  ductus  arteriosus  generally  remains  pervious, 
and  the  pulmonary  vessels  are  supplied  through  this  channel.  If 
the  ventricular  septum  be  complete,  the  foramen  ovale  continues 
open.  The  open  foramen  and  the  defect  in  the  septum  between 
the  ventricles,  instead  of  adding  to  the  danger,  afford  relief  to  the 
overloaded  right  ventricle  and  auricle,  without  which  life  would 
probably  not  continue,  except  for  a  brief  period.  The  right  ven- 
tricle becomes  greatly  dilated  and  hypertrophied  in  this  variety  of 
malformation. 

The  presence  of  a  supernumerary  septum  in  the  right  ventricle 
constitutes  another  variety  of  malformation.  This  superfluous 
septum  may  be  so  far  complete  that  the  heart  appears  to  have 
three  ventricles.  In  its  effects,  this  malformation  is  essentially 
similar  to  those  involving  obstruction  or  obliteration  of  the  pul- 
monic orifice,  and  with  the  latter  malformations  it  is  often  asso- 
ciated. The  foramen  ovale  and  ductus  arteriosus,  either  or  both, 
are  generally  open,  and  the  septum  between  the  ventricles  is,  in 
some  instances,  deficient.  The  duration  of  life  varies  according  to 
the  amount  of  obstruction.  In  the  cases  collected  by  Dr.  Peacock, 
death  occurred  between  the  ages  of  nine  and  thirty-six  3"ears. 

Certain  malformations  consist  in  the  non-occurrence  of  those 
changes  which  should  ensue  after  birth.  The  most  important  of 
these  are  patency  of  the  foramen  ovale  and  of  the  ductus  arteriosus. 
These  passages,  peculiar  and  essential  to  the  circulation  in  foetal 
life,  remain  patent,  one  or  both,  after  birth,  in  most  of  the  instances 
in  which  the  ventricular  septum  is  more  or  less  deficient,  and,  in 
general,  their  patenc}^  is  associated  with  obstruction  at  or  near  the 


MALFOEMATIONS.  235 

pulmonic  orifice.  When  the  latter  condition  coexists,  the  right 
ventricle  generally  becomes  hypertrophied,  but  to  this  rule  there 
are  exceptions.  If  the  communications  between  the  auricles  and 
the  primary  arteries  are  free,  the  right  ventricle,  instead  of  being 
enlarged,  is  sometimes  found  to  be  quite  small,  evidently  atrophied, 
the  blood  finding  a  ready  outlet  through  the  foetal  passages,  thus 
preventing  accumulation  within  the  right  ventricular  cavity.  It 
is  to  be  remarked  that  although  in  the  great  majority  of  instances 
of  open  foramen  ovale,  obstruction  at  or  near  the  pulmonic  artery 
is  associated,  the  rule  is  not  invariable.  Hence,  this  obstruction, 
although  a  frequent,  is  not  the  sole  cause  of  the  persistence  after 
birth  of  the  communication  between  the  auricles.  Patency  of  the 
ductus  arteriosus  is  also  a  conservative  provision  in  cases  of  oblite- 
ration of,  or  great  obstruction  at  the  pulmonic  orifice.  It  is  equally 
so  in  certain  instances  in  which  the  foramen  ovale  becomes  closed 
during  foetal  life.  This  duct  remains  pervious  in  some  cases  in 
consequence  of  obstruction  at  the  aortic,  and  also  at  the  mitral 
orifice.  These  coexisting  malformations  account  for  the  persistence 
of  the  open  duct  in  the  great  majority  of  cases,  but  the  latter  is 
sometimes  observed  when  it  is  not  thus  to  be  explained,  existing 
independently  of  other  abnormities  to  which  a  relation  of  depend- 
ency can  be  traced. 

Finally,  there  are  certain  malformations  which  do  not  interfere 
with  the  functions  of  the  heart,  but  which  may  lay  the  foundations 
of  disease  in  after  life.  Under  this  head  are  embraced,  on  the  one 
hand,  deficiency,  and,  on  the  other  hand,  excess  in  the  number  of 
segments  of  the  semilunar  valves.  Deficiency  is  of  more  importance 
than  excess.  In  fact,  it  does  not  appear  that  the  latter  leads  to  any 
serious  consequences.  The  former  involves,  in  certain  cases,  in- 
sufficiency and  regurgitation,  and,  probably,  a  disposition  to  take  on 
disease  greater  than  if  the  malformation  did  not  exist.  Union  of 
the  different  curtains  of  the  tricuspid  valves  is  found  not  infre- 
quently in  autopsies,  and  in  a  certain  proportion  of  these  cases, 
may  be  due  to  disease  of  intra-uterine  life.  The  proportion  of  cases 
in  which  the  lesion  dates  from  a  period  anterior  to  birth,  is  un- 
doubtedly greater  in  the  instances  of  union  of  the  curtains  of  the 
tricuspid  than  of  the  mitral  valve.  It  appears  that  the  diflerence 
in  tendency  to  valvular  disease  between  the  two  sides  of  the  heart, 
which  is  so  marked  after  birth,  is  reversed  during  foetal  life ;  in 
other  words,  the  tricuspid  valve  is  as  much  more  likely  to  take  on 
disease  before,  as  the  mitral  valve  after  birth. 


236      CONGENITAL    MISPLACEMENTS,  ETC.   OF    THE    HEART. 

To  determine  in  early  life  that  malformation  of  some  kind  exists, 
is  usually  not  difficult,  provided  the  abnormity  be  of  a  nature,  and 
sufficient  in  degree,  to  induce  marked  disorder.  Palpitation,  dys- 
pnosa,  or  cyanosis,  existing  from  birth,  or  developed  shortly  after- 
ward, and  either  persisting  or  recurring  more  or  less  frequently, 
point  to  a  congenital  difficulty.  To  determine  the  particular  kind 
of  malformation,  however,  is  a  problem  in  diagnosis  by  no  means 
always  easy.  With  reference  to  the  latter  discrimination,  it  is  im- 
portant to  bear  in  mind  that  of  a  given  number  of  malformations, 
after  the  age  of  twelve  years,  in  a  very  large  proportion  there  exists 
contraction  at  the  pulmonic  orifice.  Of  thirty-nine  cases  analyzed 
by  Dr.  Peacock,  obstruction  to  the  passage  of  blood  into  the  pul- 
monic artery  existed  in  thirty-two.  It  is  also  to  be  kept  in  view 
that  in  a  very  large  proportion  of  the  instances  in  which  obstruction 
at  the  pulmonic  orifice  exists,  either  there  is  patency  of  the  fora- 
men ovale,  or  deficiency  of  the  auricular  or  ventricular  septa,  or 
both.  If  pulmonic  obstruction  be  determined,  the  chances  are 
that  the  last  mentioned  malformations  coexist.  Guided  by  the  law 
of  probabilities,  if  a  person  survive  several  years  with  manifestly 
some  cardiac  malformation,  we  shall  seldom  err  in  presuming  that 
there  exists  pulmonic  obstruction.  But  physical  signs  may  convert 
this  presumption  into  a  conclusion  quite  positive.  A  bellows- 
murmur  referable  to  the  pulmonic  orifice  points  to  this  as  the  seat 
of  an  abnormal  condition.  We  have  seen  that  a  systolic  murmur 
may  be  referred  to  the  pulmonic  orifice.  The  maximum  of  the 
intensity  of  the  murmur  will  be  at  the  base  of  the  heart  on  the  left 
side  of  the  sternum,  or  the  murmur  may  be  limited  to  that  situation. 
It  is  not  propagated  into  the  carotids.  Attention  to  the  pulmonic 
second  sound  of  the  heart  may  afford  additional  aid  in  the  diagnosis, 
this  sound  being  found  to  be  abnormally  weak  or  wanting.  In 
connection  with  a  murmur  thus  localized,  in  a  large  proportion  of 
cases  there  will  be  present  the  physical  evidence  of  enlargement  of 
the  right  ventricle.  A  diastolic  murmur  referable  to  the  pulmonic 
orifice,  or  a  pulmonic  regurgitant  murmur,  may  be  discovered, 
especially  if  the  right  ventricle  be  hypertrophied.  I  have  lately 
met  with  such  a  murmur  distinctly  appreciable  over  the  body  of 
the  heart,  on  the  right  side  of  the  sternum,  and  at  the  xiphoid  car- 
tilage. Communication  of  the  two  ventricles  through  an  aperture 
in  the  septum,  gives  rise  to  a  systolic  murmur.  A  murmur  thus 
produced  will  not  be  propagated  either  along  the  course  of  the 
aorta  or  pulmonic  artery,  and  will  have  its  maximum  at  or  near 


MALFORMATIONS.  237 

the  base  of  the  heart.  By  these  points  its  source  may  be  deter- 
mined with  considerable  confidence,  but  not  with  positiveness,  for, 
exclusive  of  malformations,  intra- ventricular  murmurs  are  occasion- 
ally incident  to  disease  which  cannot  be  traced  either  to  the  arterial 
or  auriculo-ventricular  orifices  by  the  ordinary  rules  of  localization. 
The  passage  of  blood  through  an  open  foramen  ovale  probably 
rarely,  if  ever,  gives  rise  to  a  murmur.'  The  clinical  study  of  cases 
of  malformation,  with  respect  to  the  physical  signs,  is  highly  in- 
teresting, and  claims  more  attention  than  it  has  as  yet  received. 

Of  the  causes  of  death  in  the  various  forms  of  malformation,  the 
most  frequent  are,  1st.  Cerebral  disturbance  resulting  from  the 
defective  aeration  of  the  blood  and  congestion  of  the  brain ;  and, 
2d.  Imperfect  expansion,  collapse  and  engorgement  of  the  lungs. 
It  is  worthy  of  note  that  dropsical  effusions,  so  common  in  lesions 
of  the  heart  originating  after  birth,  occur  less  frequently  than 
would  be  expected  from  the  obstruction  to  the  circulation  incident 
to  many  of  the  malformations.  Death  occurs  not  very  infrequently 
from  tuberculosis  in  the  cases  in  which  life  is  prolonged  for  several 
years.  Of  56  cases,  analyzed  by  Dr.  Peacock,  in  which  patients 
afiected  with  different  forms  of  malformation  survived  the  a2:e  of 
eight  years,  in  9  tuberculosis  became  developed,  being  a  ratio  of 
16.07  per  cent.  In  six  of  the  nine  tuberculosis  cases  cyanosis 
existed  in  a  marked  degree.  This  appears  to  militate  against  the 
incompatibility  of  tuberculous  disease  and  venosity  of  the  blood,  as 
asserted  by  Eokitansky.  It  is,  however,  certain  that  diseases  of 
the  heart  developed  after  birth,  and  phthisis  are  rarely  associated; 
and  the  inquiry  arises,  whether  there  is  a  law  here  applicable  to 
morbid  conditions  and  not  to  malformations.  This  is  a  question  to 
be  settled  by  further  statistical  data. 

The  general  principles  of  treatment  in  cases  of  malformation, 
may  be  embraced  in  a  very  few  words.  They  relate  to  measures 
to  protect  against  cold ;  avoidance  of  over-exertion  and  great  mental 
excitement ;  together  with  such  palliative  measures  as  the  particu- 
lar circumstances  in  individual  cases  may  indicate.^ 

'  In  six  cases  of  open  foramen  ovale,  reported  by  John  W.  Ogle,  M.  D.,  assistant 
physician  at  St.  George's  Hospital,  London,  no  murmur  was  discovered  during 
life. — British  Med.  Journ.,  p.  500,  1857,  from  Journal  de  la  Physiologic,  etc.,  publie 
sous  la  direction  du  Docteur  E.  Brown-Sequard,  Janvier,  1850. 

2  It  is  proper  to  state  that  the  foregoing  account  of  congenital  affections  has  been 
mostly  borrowed  from  an  analytical  review  of  Dr.  Peacock's  work,  written  by  the 
author,  and  contained  in  the  American  Journal  of  Medical  Sciences,  ^"o.  for  July, 
1858. 


238      COXGEXITAL    MISPLACEMENTS,  ETC.   OF    THE    HEART, 


CYANOSIS. 


Blueness,  or  a  purple  color  of  the  surface  of  the  body  and  the 
mucous  surfaces  open  to  observation,  occurring  in  connection  with 
malformations  of  the  heart,  has  been  considered  as  constituting  an 
aft'ection  called  cyanosis,'  morbus  creruleus,  or  blue  disease.  For 
the  sake  of  precision,  these  names  should  be  restricted,  as  they 
usually  are,  to  the  peculiar  coloration  due  to  abnormal  conditions 
which  are  congenital,  although  this  effect  may  not  be  manifested  for 
some  time  after  birth.  But  an  analogous,  if  not  identical  appearance 
of  the  integument  is  observed  in  some  cases  of  organic  disease  of 
the  heart  developed  at  different  periods  of  life,  and  also  independ- 
ently of  any  cardiac  lesions.  It  is  well  marked,  for  example,  in 
the  algid,  or,  as  it  is  often  termed,  the  cyanotic  stage  of  epidemic 
cholera.  This  fact  is  to  be  borne  in  mind  with  reference  to  the 
rationale  of  the  blueness  which  characterizes  certain  cases  of  car- 
diac malformation.  The  nature  of  the  connection  existing  between 
cyanosis  and.  malformations  of  the  heart,  has  been  much  discussed, 
and  is  still  open  for  discussion.  To  consider  the  subject  at  much 
length,  would  be  inconsistent  with  the  practical  character  of  this 
work.  I  shall  therefore  present,  very  briefly,  the  views  which 
seem  to  comport  best  with  our  present  knowledge. 

Cyanosis  was  attributed  by  Morgagni  to  congestion  of  the  venous 
system  caused  by  obstruction  at  the  origin  of  the  pulmonic  artery. 
John  Hunter  attributed  it  to  the  admixture  of  venous  and  arterial 
blood  in  consequence  of  abnormal  communication  between  the 
auricles  or  ventricles,  or  an  abnormal  arrangement  of  the  primary 
vessels.  The  latter  was  the  current  doctrine  until  within  the  past 
few  years  the  explanation  of  Morgagni  has  been  revived  and  main- 
tained by  several  distinguished  pathologists — Louis  and  Yalleix  in 
France,  Hasse  and  Eokitansky  in  Germany,  Jay  and  Peacock  in 
England,  and  the  late  Moreton  Stille,  of  this  country,"  Many 
distinguished  pathologists,  however,  still  adhere  to  the  Hunterian 
theory,  while  some  adopt  both  explanations,  referring  the  affection 
in  certain  cases  to  venous  congestion  solely ;  in  other  cases,  to  the 

'  xuavsc,  blue,  and  vsVcc,  disease. 

'  On  Cyanosis,  or  Morbus  Czeruleus,  by  Moreton  Stille,  M.  D.,  American  Journal 
of  Medical  Sciences,  new  series,  vol.  viii.,  1844,  p.  25. 


CYANOSIS.  239 

admixture  of  the  two  kinds  of  blood,  or  to  the  combination  of  these 
two  abnormal  conditions. 

In  the  endeavor  to  settle  upon  the  true  explanation  of  cyanosis, 
the  first  and  most  important  point  of  inquiry  is,  whether  it  be 
uniformly  associated  with  any  particular  class  of  malformations. 
This  point  is  not  readily  ascertained,  because,  in  the  great  majority 
of  cases,  malformation  does  not  consist  of  a  single  abnormity,  but 
several  abnormal  conditions  are  combined.  Thus,  obliteration  or 
obstruction  of  the  pulmonic  orifice  generally  involves  an  open 
foramen  ovale  or  deficiency  of  the  ventricular  septum.  The  former 
induces  congestion  of  the  venous  system;  the  latter  occasions 
admixture  of  the  venous  and  arterial  blood.  Analyses  of  large 
collections  of  cases,  in  fact,  show  that,  in  by  far  the  greater  number, 
there  exist  pulmonic  contraction,  and,  at  the  same  time,  communi- 
cation between  either  the  ventricles  or  auricles,  or  both.  Of  62  of 
the  cases  collated  by  Stillt^,  in  which  the  condition  of  the  pulmo- 
nary artery  was  reported,  in  53  it  was  obstructed  or  impervious. 
In  the  remaining  9  cases,  the  author  concludes  that  the  abnormal 
conditions  present  were  of  a  nature  to  give  rise  to  congestion  of 
the  venous  system.  On  the  other  hand,  in  5  only  out  of  71  cases 
collected  by  the  same  author  was  communication  between  the  two 
sides  of  the  heart  wanting.  Cyanosis  has  been  observed  when  the 
foramen  ovale  was  not  open,  and  there  was  no  deficiency  of  the 
ventricular  septum,  nor  transposition  of  the  primary  vessels ;  and 
contraction  of  the  pulmonic  orifice  is  not  always  present.  Again, 
cases  have  been  reported  in  whicb  the  two  kinds  of  blood  must 
have  been  very  freely  mixed,  as  in  some  instances  in  which  there 
existed  a  single  ventricle,  without  cyanosis;  and  cases  of  great  con- 
genital pulmonic  obstruction  have  been  observed  without  cyanosis. 

In  short,  constancy  of  connection  with  any  particular  class  of 
malformations  is  not,  as  yet,  established.  Cyanosis  cannot  be 
considered  as  having  any  fixed  special  anatomical  character.  It 
may  be  associated  with  numerous  and  different  abnormal  conditions. 

Continuing  to  regard  the  different  forms  of  malformation  as 
giving  rise  either  to  venous  congestion  or  admixture  of  the  two 
kinds  of  blood  (although,  as  has  been  seen,  both  effects  are  usually 
combined),  the  facts  adduced  by  Stille,  Peacock,  and  others,  appear 
to  show  conclusively  that  the  former  effect  is  concerned  in  the 
production  of  cyanosis  much  oftener  and  to  a  much  greater  extent 
than  the  latter.  The  exceptions  to  the  rule  that  obstruction  either 
at  the  pulmonic  orifice  or  elsewhere,  inducing  congestion  of  the 


2-iO      CONGENITAL    MISPLACEMENTS,  ETC.   OF    THE    HEART. 

veins  and  venous  radicles,  exists  in  cases  of  cyanosis,  must  be 
exceedingly  infrequent,  if,  indeed,  there  are  any  exceptions  to  the 
rule,  and  the  instances  in  which  great  congenital  obstruction  at  the 
pulmonic  orifice  are  not  attended  by  cyanosis,  may,  perhaps,  be 
explained,  as  suggested  by  Dr.  Peacock,  by  supposing  that  the 
right  ventricle  becomes,  under  these  circumstances,  sufficiently 
hypertrophied  to  compensate  for  the  obstruction  by  the  increased 
power  of  its  contractions.  The  researches  of  Stille  have  sufficiently 
established  the  fact,  already  stated,  that  the  most  complete  com- 
mingling of  arterial  and  venous  blood,  either  by  direct  communi- 
cation between  the  two  sides  of  the  heart  or  by  mal-arrangement 
of  the  vessels,  is  not  always  adequate  to  give  rise  to  cyanosis ;  and 
that,  as  regards  intensity,  cyanosis  bears  no  constant  relation  to 
the  freedom  of  communication  between  the  two  sides  of  the  heart 
or  the  different  systems  of  vessels.  But  the  establishment  of  these 
facts  does  not  prove  that  the  commingling  of  the  two  kinds  of 
blood  is  never  involved  in  the  production  of  cyanosis.  That  in 
certain  cases  this  is  an  important  element  is  probable.  It  is 
evident  that  the  coexistence  of  pulmonic  obstruction  with  either  an 
open  foramen  ovale  or  deficiency  in  the  ventricular  septum  must 
contribute  in  no  small  measure  to  the  admixture  of  the  blood 
through  these  communications;  and  hence  it  is  intelligible  that 
when  these  malformations  are  combined  (as  they  usually  are), 
cyanosis  is  much  more  likely  to  be  the  result  than  when  either 
exists  independently  of  the  other. 

The  general  conclusions,  then,  most  consistent  with  our  present 
knowledge  of  the  subject  are  that  cyanosis  involves,  in  the  vast 
majority  of  cases,  if  not  invariably,  venous  congestion  due  to  con- 
traction or  obliteration  of  the  pulmonic  artery,  or  to  some  other 
malformation  which  occasions  obstruction  to  the  flow  of  blood  from 
the  systemic  veins;  that  it  may  be  produced  by  obstruction  alone 
without  any  admixture  of  the  arterial  and  the  venous  blood,  but 
that  the  latter  may  contribute,  more  or  less,  to  its  production. 
The  presence  of  venous  blood  in  the  arterial  system,  it  is  to  be 
remarked,  contributes,  not  alone  by  the  purple  color  which  it 
acquires  from  the  admixture  to  the  cyanosis,  but  by  increasing  the 
venous  congestion.  The  capillary  circulation  is  impeded,  and  the 
flow  of  blood  through  the  veins  retarded  in  proportion  to  the 
venosity  of  the  arterial  blood. 

The  blueness  of  the  skin  in  cyanosis  is  due,  of  course,  to  the 
blood  contained  in  the  minute  or  capillary  vessels.     Now,  inasmuch 


CYANOSIS.  241 

as  obstruction  of  the  venous  system  occurs,  frequently  in  a  great 
degree,  in  cases  of  organic  lesions  of  the  heart  arising  from  disease 
developed  after  birth,  the  question  arises,  why  is  it  that  cyanosis  is 
peculiar  to,  or  at  least  occurs  so  much  oftener  and  to  a  greater 
extent  in  connection  with  congenital  affections  ?  It  is  highly  pro- 
bable that  the  answer  to  this  inquiry  is  contained  in  a  suggestion 
by  Dr.  Chevers,^  viz.,  that  the  capillary  vessels  become  much  more 
largely  expanded  when  obstruction  to  the  circulation  exists  before 
birth,  or  prior  to  the  full  development  of  the  body,  the  vascular 
system  being  more  readily  dilatable,  than  in  the  adult.  Cyanotic 
phenomena,  however,  are  not  exclusively  observed  in  connection 
with  malformations.  They  may  be  developed  at  any  age  as  a 
result  of  obstruction  at  the  right  side  of  the  heart  in  conjunction 
with  deficient  aeration  of  the  blood.  They  are  seen  in  *cases  of 
pulmonary  obstruction  due  to  atelectasis,  collapse  of  lung,  capil- 
lary  bronchitis,  etc.  They  are  well  marked,  as  already  stated, 
in  the  blue  stage  of  epidemic  cholera,  being  dependent,  in  the 
latter  affection,  in  a  great  measure,  on  capillary  congestion  pro- 
ceeding from  the  abnormal  condition  of  the  blood  itself.  The 
appearance  of  the  tegumentary  surfaces  in  these  various  affections 
does  not  differ  essentially  from  that  in  cyanosis,  the  main  difference 
being  that  the  blueness  or  lividity  is  very  rarely,  if  ever,  so 
extreme  as  in  the  cases  in  which  it  is  dependent  on  congenital 
affections. 

The  discoloration  in  different  cases  of  cyanosis  differs  greatly 
in  degree.  Between  slight  blueness  and  darkness  approaching 
nearly  to  blackness,  in  a  sufficient  variety  of  cases,  every  degree  of 
gradation  will  be  manifested.  All  portions  of  the  body  are  not 
alike  affected.  Certain  parts,  viz.,  the  lips,  around  the  eyes,  the 
cheeks,  the  ears,  the  extremity  of  the  nose,  the  roots  of  the  finger 
nails,  and  the  genital  organs,  present  a  change  in  color  more  marked 
than  over  the  surface  generally.  The  blueness  may  be  limited  to 
parts  in  which  the  skin  is  delicate  and  the  capillary  vessels  abun- 
dant. The  degree  of  discoloration  varies  also  greatly  at  diflferent 
periods  in  the  same  case.  Its  intensity  is  increased  by  fits  of  cough- 
ing, muscular  exercise,  mental  emotions,  and  any  cause  which 
excites  the  action  of  the  heart.  The  cyanosis  may  exist  only  under 
these  circumstances,  being  absent  when  the  heart  is  tranquil.  It 
is  always  increased  by  any  intercurrent  pulmonary  or  cardiac 
disease. 

'  Dr.  Peacock,  op.  cit.,  p.  128. 

16 


242      CONGENITAL    MISPLACEMENTS,  ETC.   OF    THE    HEART. 

Although  dependent  on  malformations,  cyanosis  is  not  always 
manifested  at  or  immediately  after  birth.  Of  71  cases  analyzed  by 
Stillo  with,  respect  to  this  point,  it  was  congenital  in  40,  and 
occurred  in  the  remaining  31  cases  at  various  periods  after  birth. 
It  may  not  occur  until  several  years  after  birth.  When  this  is  the 
case,  it  is  reasonable  to  presume  that  some  disease  of  the  heart  or 
lungs  has  been  added  to  the  malformations,  increasing  the  venous 
obstruction  occasioned  by  the  latter.  It  has  been  observed  to  follow 
a  blow  on  the  chest.  The  development  of  cyanosis  after  birth  has 
been  accounted  for  by  supposing  that  in  these  cases  a  communication 
between  the  two  sides  of  the  heart  either  takes  place  or  is  enlarged 
at  the  time  when  the  cyanosis  occurs.  Eupture  or  perforation  of 
the  foramen  ovale  may  happen  after  birth,  or  the  size  of  an  existing 
aperture  may  be  increased.  The  same  may  be  said  with  regard 
to  the  interventricular  septum  at  the  undefended  space.  This  ex- 
planation is  based  on  the  supposed  importance  of  the  admixture  of 
the  venous  and  arterial  blood  in  the  production  of  cyanosis.  That 
it  is  applicable  to  certain  cases  is  not  improbable.  On  the  other  hand, 
cyanosis  in  some  instances  exists  at  birth  and  afterwards  diminishes. 
It  may  even  disappear;  but  such  cases  must  be  extremely  rare. 

Although  cyanosis  is  regarded  as  a  distinct  affection,  it  is  suffi- 
ciently evident  that  it  is  only  a  symptom  of  certain  congenital 
affections  of  the  heart.  It  has  no  claim  to  be  considered  as  an 
individual  disease.  It  is  associated  with  other  symptoms  of  malfor- 
mation, viz.,  palpitation,  dyspnoea,  etc.  "When  present,  habitually, 
in  a  marked  degree,  the  patient  generally  is  remarkably  susceptible 
to  cold,  and  the  temperature  of  the  body  is  lowered.  The  muscular 
power  is  deficient.  The  muscles  do  not  attain  to  a  full  develop- 
ment. The  faculties  of  the  mind  are  also  often  imperfectly 
developed  and  feeble.  Enlargement  of  the  pulpy  extremities  of 
the  fingers,  with  incurvation  of  the  nails,  constituting  what  is  called 
"  clubbed  fingers,"  is  observed  in  some  cases.  I  have  met  with 
this  charge  in  a  marked  degree,  in  connection  with  organic  lesions 
of  the  heart  occurring  after  adult  age,  not  associated  with  tubercu- 
losis of  the  lungs. 

The  diagnosis  rarely  involves  much  difficulty.  Discoloration  of 
the  surface,  either  general  or  partial,  present  habituall}'-,  or  occur- 
ring whenever  the  action  of  the  heart  is  excited ;  existing  at,  or 
developed  shortly  after  birth  in  the  great  majority  of  instances; 
accompanied  by  palpitation,  dyspnoea,  tendency  to  syncope,  etc., 
either  constantly  or  in  paroxysms;  muscular  weakness,  abnormal 


CYANOSIS.  243 

coolness  of  the  surface  and  susceptibility  to  cold  ;  these  are  diag- 
nostic points  pertaining  to  the  symptoms.  In  addition  to  these 
points,  physical  signs  denoting  malformation  of  the  heart  are 
generally  determinable,  consisting  of  those  which  denote  enlarge- 
ment of  the  organ,  together  with  organic  murmurs,  the  latter  being 
often  referable  to  the  pulmonic  orifice.  The  lividity  due  to  certain 
pulmonary  affections  in  children,  is  to  be  discriminated  by  the 
previous  history,  taken  in  connection  with  the  presence  of  symp- 
toms and  signs  pointing  to  the  lungs  as  the  seat  of  disease,  and  the 
absence  of  the  symptoms  and  signs  of  malformation  of  the  heart. 

The  prognosis  in  cases  of  malformation  of  the  heart  accompanied 
by  cyanosis,  is  unfavorable.  If  the  discoloration  be  congenital,  in- 
tense, and  persisting,  it  denotes  a  condition  of  the  heart  which  is 
generally  incompatible  with  a  duration  of  life  beyond  a  few,  weeks 
or  months.  If  moderate  or  slight,  or  occurring  only  in  paroxysms, 
patients  sometimes  live  for  many  years,  and  even  long  life  is  pos- 
sible. The  statistics  collected  by  Stills  with  regard  to  the  duration 
of  the  disease,  show,  at  a  glance,  the  diversity  of  cases  in  this  re- 
spect. Of  40  cases,  in  all  of  which  the  cyanosis  was  congenital, 
death  occurred  within  23  days  after  birth  in  seven;  between  23 
days  and  10  weeks,  in  three;  between  10  weeks  and  1  year,  in  seven; 
between  1  year  and  10  years,  in  ten;  between  10  years  and  20  years, 
in  ten.  Of  these  40  cases  life  was  prolonged  to  29  years,  to  35 
years,  and  to  57  years,  respectively,  in  a  single  instance. 

The  treatment  of  cyanosis  resolves  itself  into  that  of  malforma- 
tions of  the  heart.  The  few  remarks  already  made  comprise  all 
that  it  is  necessary  to  say  under  this  head. 


CHAPTEPv   VI. 

CERTAIN    AFFECTIONS    INCIDENTAL   TO    ORGANIC 
DISEASES    OF   THE    HEART. 

Formation  op  Clots  aud  Fibrinous  Coagula  in  the  Cavities  of  the  Heart. — Clots 
formed  after  death  and  at  the  close  of  life — Fibrinous  coagula  formed  during  life — Their 
pathological  connections — Their  formation  in  organic  affections  of  the  heart — Symptoms 
denoting  their  formation — Physical  signs  and  diagnosis — Prognosis — Treatment. 

Polypi  of  the  Heart. 

Angina  Pectoris. — Symptoms  characteristic  of— Description  of  paroxysms — Exciting 
causes — Pathological  character  and  relations — Infrequency  of  the  affection — Influence 
of  age  and  sex — Gravity  and  prognosis — Diagnosis — Treatment. 

Enlargement  of  the  Thyroid  Body  and  Prominence  of  the  Eyes. — Phenomena 
descriptive  of  the  enlargement  of  the  thyroid  body — Morbid  appearances  of  the  heart  in 
fatal  cases — Cases  observed  by  the  author — Supposed  pathological  connection  -with  ex- 
cessive action  of  the  heart — Phenomena  descriptive  of  the  prominence  of  the  eyes — 
Different  explanations — Diagnosis — Prognosis  in  cases  of  enlargement  of  the  thyroid 
body  and  prominence  of  the  eyes — Indications  for  treatment. 

Keduplication  of  the  Heart-Sounds. — Different  varieties  of  reduplication  and  their 
relative  infrequency — Cases  of  reduplication  of  both  sounds — Cardiac  lesions  found  after 
death  in  cases  of  reduplication — Mechanism  of  reduplication — Bearing  of  the  facts  per- 
taining to  reduplication  on  the  mechanism  of  the  normal  heart-sounds — Mode  of  distin- 
guishing the  different  varieties  of  reduplication — Pathological  import  and  diagnostic 
significance  of  reduplications — Treatment. 

The  caption  to  this  chapter  includes  several  pathological  events 
which  are  liable  to  occur  in  cases  of  organic  disease  of  the  heart,  but 
which  do  not  belong  exclusively  to  the  clinical  history  of  any  par- 
ticular lesions.  They  occur  in  different  forms  of  organic  disease, 
and  all  of  them  do  not  involve,  of  necessity,  the  existence  of  an 
antecedent  structural  lesion.  Hence,  although  these  events  are 
quite  dissimilar  in  character,  they  may  conveniently  be  grouped 
together.  The  first  of  these  events  which  will  be  considered  is  the 
formation  of  clots  and  fibrinous  coagula  within  the  cavities  of  the 
heart ;  the  second  is  the  occurrence  of  pain  and  other  symptoms  in 
paroxysms,  commonly  known  as  angina  pectoris;  enlargement  of 
the  thyroid  body  and  prominence  of  the  eyeball  will  be  next  noticed, 
and,  finally,  reduplication  of  the  heart-sounds.  These  subjects  will 
be  treated  of  only  so  far  as,  with  our  present  knowledge,  they  are 
of  interest  and  importance  in  a  practical  point  of  view. 


FIBEINOUS    COAGULA    WITHIN    THE    HEART.  245 


FORMATION  OF   CLOTS  AND  FIBRINOUS  COAGULA  WITHIN 
THE   CAVITIES   OF   THE   HEART. 


The  cavities  of  the  heart  are  usually  found  to  contain,  after 
death,  coagulated  blood,  or  clots,  in  more  or  less  abundance. 
These  are  found  oftener  and  in  greater  abundance  in  the  right 
auricle  and  ventricle  than  in  the  cavities  of  the  left  side  of  the 
heart.  This  is  owing  to  the  fact  that,  at  the  time  of  death,  the 
cavities  of  the  right  side  of  the  heart  contain,  in  general,  a  much 
larger  quantity  of  blood  than  the  left  auricle  and  ventricle.  Other 
things  being  equal,  the  size  and  number  of  clots  will  be  propor- 
tionate to  the  amount  of  blood  remaining  in  the  heart-cavities  after 
life  has  ceased.  The  clots  to  which  reference  is  now  made  are 
formed  post-mortem.  The  blood  in  the  cavities  coagulates  after 
death,  as  it  does  when  drawn  from  the  vessels  by  venesection 
during  life.  These  clots  are  variable  as  regards  size,  form,  consist- 
ence, and  color.  They  are  sometimes  uniformly  dark  and  friable. 
In  other  instances  they  are  more  resisting,  but  never  extremely 
dense,  and  present,  on  the  surface  extending  more  or  less  over  the 
periphery,  a  layer  of  fibrin  devoid  of  red  globules,  or  hasmatin. 
The  latter  is  identical  with  the  buffy  coating  of  blood  coagulated, 
in  certain  cases,  after  venesection.  It  is  sometimes  tolerably  firm, 
and,  in  some  instances,  probably  from  the  imbibition  of  serum,  it 
is  of  a  soft,  jelly-like  consistence.  A  distinctive  feature  of  the  clots 
now  referred  to  is,  they  are  loose,  i.  e.,  not  attached  to  the  endo- 
cardium, and  not  strongly  intertwined  with  the  tendinous  cords  or 
fleshy  columns.  They  may  extend  from  one  cavity  to  another 
through  the  auriculo- ventricular  orifices,  and  into  the  large  vessels, 
the  arteries  and  veins,  connected  with  the  heart.  It  is  not  uncom- 
mon to  find  prolongations  of  considerable  length  contained  in  the 
large  arteries,  especially  the  pulmonic  artery,  consisting  of  fibrin, 
more  or  less  solid,  and  colored,  to  a  greater  or  less  extent,  by  the 
presence  of  red  globules.  The  occurrence  of  post-mortem  clots  un- 
doubtedly depends,  in  a  great  measure,  on  the  condition  of  the 
blood.  They  are  more  likely  to  be  formed  in  those  diseases  in 
which  the  fibrinous  constituent  of  the  blood  is  in  excess  (hyperino- 
sis)  ;  and,  under  these  circumstances,  .the  proportion  of  colorless 
fibrin  in  the  clots  will  be  increased.     On  the  other  hand,  after 


246      AFFECTIONS   INCIDENTAL    TO    ORGANIC    DISEASES. 

certain  fiital  affections,  as  is  well  known,  the  blood  coagulates 
imperfectly,  and  sometimes  not  at  all,  the  cavities  of  the  heart 
being  filled  with  blood  entirely  liquid. 

To  the  clots  just  described  the  older  pathologists  attached  much 
importance.  They  were  regarded  as  ante-mortem  productions,  and 
included  in  the  class  of  the  so-called  'polypi  of  the  heart,  being 
supposed  to  give  rise  to  a  multitude  of  symptoms  during  life,  and 
to  be  frequently  the  cause  of  death.  That  they  are  formed  after 
death  is  certain,  but  the  question  arises,  whether  they  may  not 
sometimes  be  formed  during  the  last  moments  or  hours  of  life,  and, 
in  fact,  prove  the  immediate  occasion  of  the  cessation  of  the  circu- 
lation. It  is  difficult,  and  indeed  impossible,  to  settle  this  que^ion 
demonstratively,  but  the  affirmative  is  highly  probable.  That 
coagulation  does  take  place  before  death  in  certain  cases,  and 
arrests  the  circulation,  is  not  to  be  doubted.  The  coao:ula  that  are 
indubitably  of  ante-mortem  formation  will  be  presently  considered. 
The  question  now  relates  to  clots,  loose  or  unattached,  and  not 
differing  from  those  which  are  due  to  coagulation  after  death.  It 
may  be  readily  conceived  that  in  certain  diseases  of  the  heart,  and 
in  various  affections  exclusive  of  these,  at  the  close  of  life,  when 
the  circulation  becomes  so  enfeebled  that  the  blood  accumulates 
and  remains  nearly  stagnant  in  the  cavities,  coagulation  may  take 
place,  and,  to  quote  the  language  of  Prof.  Meigs,  "the  last  fatal 
blow  is  struck  by  the  formation  of  a  heart-clot  of  greater  or  less 
size."  The  distinguished  author  just  named  accounts  in  this  way 
for  sudden  death,  in  some  puerperal  cases,  during  syncope  induced 
by  assuming  suddenly  the  erect  posture,  when  recent  delivery  has 
been  accompanied  or  followed  by  a  large  amount  of  hemorrhage.^ 
The  explanation  is,  to  say  the  least,  plausible ;  and  its  extension, 
by  the  same  author,  to  account  for  the  final  cessation  of  the  circu- 
lation in  various  chronic  and  acute  diseases,  is  not  irrational. 
This,  however,  can  only  be  a  matter  for  conjecture,  since  the  clots 
found  in  the  cavities  of  the  heart  do  not  differ  from  those  which 
are  formed  by  coagulation  after  death. 

Masses  of  considerable  size,  consisting  of  coagulated  fibrin,  are 
often  found  in  the  cavities  of  the  heart  in  post-mortem  examina- 
tions which  furnish  intrinsic  evidence  of  having  been  formed 
during  life.     This  evidence  consists  in  their  density,  the  absence  of 

'  Vide  paper  by  Prof.  C.  D.  Meigs,  in  the  Philadelphia  Medical  Examiner,  March, 
1849.     Also  treatise  on  Obstetrics. 


FIBRINOUS    COAGULA    WITHIN    THE    HEART.  247 

red  globules,  intertwining  with  the  tendinous  cords  and  fleshy 
columns,  adhesion  to  the  endocardium,  grooving  of  their  surfaces 
by  the  currents  of  blood,  and  certain  changes  due  to  molecular 
disintegration  or  decomposition.      These   characters   denote   that 
they  are  not  produced  by  coagulation  after  death,  nor  as  the  final 
event  in  the  act  of  dying,  although  they  frequently  prove  the  im- 
mediate cause  of  the  arrest  of  the  circulation.     The  date  of  their 
formation  may  be   days   and   possibly  weeks   anterior  to  death. 
These  coagula  differ  greatly  in  size  and  configuration.     They  may 
be  formed  in  the  cavities  of  the  left,  as  well  as  in  those  of  the  right 
side  of  the  heart,  but  more  frequently  in  the  latter,  and  oftener  in 
the  auricle  than  in  the  ventricle.     They  are  frequently  connected 
with  the  tendinous  cords  or  fleshy  columns,  with  which  they  are 
often  very  closely  and  strongly  intertwined,  the  latter  fact  being 
alone  sufficient  to  show  their  ante-mortem  formation.     The  play  of 
the  valves,  when  coagulation  is  taking  place,  causes  the  fibrin  to 
adhere  to  these  parts,  precisely  as  it  is  collected  for  experimental 
purposes,  by  whipping  with  a  bundle  of  small  sticks  blood  drawn 
from  the  body.     By  this  whipping  process  the  red  corpuscles  are 
expelled,  and  the  coagula  consist  of  pure  fibrin.     They  are  some- 
times closely  adherent  to  the  endocardium,  but  it  may  be  doubted 
if  this  ever  occurs  by  means  of  an  organized  attachment.     In  the 
instances  in  which  they  seem  to  be  grafted  into  the  heart,  the 
coagulated  fibrin  is  probably  deposited  on  an  organized  exudation 
or  morbid  growth.     The  opinion  held  by  Hope,  and  even  by  some 
eminent  pathologists  of  the  present  day,  that  masses  of  coagulated 
fibrin  may  become  organized,  increase  by  a  process  of  growth,  and 
undergo  transformations  of  texture  dependent  on  abnormal  nutri- 
tion, must  be  considered  untenable.     In  the  heart,  as  elsewhere, 
the  fibrinous  element  of  the  blood,  whenever  isolated  and  solidified, 
becomes,  virtually,  a  foreign  substance  incapable  of  organization. 
The  fibrinous  masses  are  sometimes  found  to  contain  collections  of 
liquid,  varying  in  color  and  consistence,  presenting  an  appearance 
of  unilocular  or  multilocular  cysts.     They  have  been  said  to  con- 
tain pus  and  softened  tuberculous  deposit.     The  latter  statement 
has  not  been  substantiated  by  adequate  examinations.     Either  the 
liquefied  portions  have  been  imbibed  from  without  or  they  are  due 
to  disintegration  or  decomposition  commencing  within  the  solid 
masses;  and  although  these  portions  may  present  the  gross  appear- 
ances of  purulent  or  tuberculous  matter,  the  microscopical  charac- 
ters of  the  latter  are  wanting. 


248      AFFECTIONS    INCIDENTAL    TO    ORGANIC    DISEASES. 

In  this  account  of  fibrinous  coagula,  reference  is  had  to  the 
formation  of  masses  of  considerable  size,  attributable  to  coagulation. 
They  are  to  be  distinguished  from  the  deposits  due  to  exudation, 
in  other  words,  concretions  of  lymph,  the  size  of  which  may  be  in- 
creased by  layers  of  fibrin,  constituting  the  vegetations  or  excres- 
cences so  often  found  attached  to  the  valves  and  orifices  of  the 
heart.  These  have  been  already  noticed  in  treating  of  valvular 
lesions,  and  they  will  be  again  considered  in  connection  with  endo- 
carditis. They  differ  from  the  formations  now  under  consideration 
in  this  respect,  viz :  they  occur  almost  exclusively  in  the  cavities 
of  the  left  side  of  the  heart,  and  more  especially  in  the  left  ventricle. 

Fibrinous  coagula  occur  in  various  pathological  connections, 
some  of  which  are,  as  yet,  imperfectly  understood.  They  occur 
as  a  result  of  the  accumulation  and  stagnation  of  blood  in  the 
cavities  of  the  heart.  So  far,  the  conditions  involved  in  their  form- 
ation are  mechanical.  Conditions  pertaining  to  the  blood  itself 
favor,  and  may  be  sufficient  for  their  formation.  One  of  these  con- 
ditions is  an  inordinate  proportion  of  fibrin,  either  from  its  being 
positively  increased,  or  relatively,  in  consequence  of  the  other  con- 
stituents of  the  blood  being  diminished.  Hence,  fibrinous  coagula 
are  liable  to  occur  in  certain  affections  characterized  by  the  excess 
of  fibrin  in  the  blood,  especially  when  the  mechanical  conditions 
are  combined.  This  combination  exists  especially  in  pneumonia, 
and  in  a  large  proportion  of  the  fatal  cases  of  this  disease,  coagula 
are  found  which  must  have  been  formed  during  life.^  It  also  exists 
in  cases  of  death  after  excessive  loss  of  fluids,  as  in  epidemic  cholera. 
Inflammation  of  the  endocardium  disposes  to  coagulation,  partly 
from  the  presence  of  deposits  of  exuded  lymph,  and  perhaps,  also, 
as  stated  by  Eokitansky,  from  the  contamination  of  the  blood  in 
consequence  of  the  admixture  of  the  inflammatory  products  carried 
into  the  circulation.  If  this  latter  statement  be  correct,  it  is  intel- 
ligible that  a  similar  contamination  from  the  products  of  inflam- 
mation derived  from  other  situations  than  the  heart,  may  lead  to 
the  same  result.  The  formation  of  fibrinous  coagula  is  by  no  means 
limited  to  cases  in  which  the  heart  is  diseased.     Some  years  since 

'  Vide  Traite  Pratique  de  la  Pneumonie,  par  Grisolle.  GrisoUe  establishes  by 
comparative  observations,  that  dense  fibrinous  coagula,  adherent  or  closely  inter- 
twined with  the  tendinous  cords  or  fleshy  columns,  are  not  only  often  found  after 
death  in  cases  of  pneumonia,  but  rarely  in  fatal  cases  of  typhoid  fever,  peritonitis, 
eruptive  fevers,  and  cerebral  maladies.  Op.  cit.,  1841,  p.  70  et  seq.  See,  also, 
Kichardsons  prize  essay  On  the  Cause  of  the  Coagulation  of  the  Blood,  London,  185S. 


FIBBINOUS    COAGULA    WITHIN    THE    HEART.  249 

a  heart  was  presented  to  me  by  my  friend,  Dr.  C.  H.  Baker,  in 
which  the  curtains  of  the  tricuspid  valve  were  literally. tied  firmly 
together  by  a  mass  of  dense,  colorless  fibrin,  portions  of  which  were 
closely  intertwined  with  the  tendinous  cords  and  papillary  muscles, 
a  prolongation  of  the  fibrinous  mass  extending  into  the  right  auricle. 
The  obstruction  of  the  right  auriculo-ventricular  orifice  was  com- 
plete. The  person  had  been  in  ill  health,  but  complaining  of  no 
definite  ailments,  and  not  under  medical  treatment.  He  was  found 
dead  in  bed,  and  an  examination  made  under  the  direction  of  the 
coroner  disclosed  no  other  cause  of  death  than  that  stated.  The 
heart,  exclusive  of  the  fibrinous  mass  mentioned,  was  devoid  of 
morbid  appearances.  It  was  not  enlarged,  and  the  valves  were 
sound.  The  various  pathological  conditions,  irrespective  of  those 
pertaining  to  the  heart,  under  whicb  fibrinous  coagula  are  formed, 
constitute  a  field  for  clinical  study,  which  claims  more  attention 
than  it  has  as  yet  received.  I  shall  content  myself  with  this  remark, 
and  proceed  to  consider  the  formation  of  coagula  as  incidental  to 
organic  affections  of  the  heart.^ 

The  conditions  derived  from  organic  lesions  of  the  heart,  under 
which  fibrinous  coagula  are  liable  to  occur,  are  mainly  mechanical, 
consisting  of  the  accumulation  and  stagnation  of  blood  within  the 
cavities.  The  latter  effects,  as  has  been  seen,  follow  obstruction  of 
the  orifices  and  dilatation  with  great  weakness  of  the  organ.  In 
cases  of  mitral  obstruction  which  has  eventuated  in  dilatation  of 
the  right  side  of  the  heart,  the  time  arrives,  if  life  be  sufficiently 
prolonged,  when  the  right  ventricle  and  auricle  are  constantly  dis- 
tended, the  ventricular  contractions  being  so  feeble  as  to  propel  but 
a  small  quantity  of  blood  into  the  engorged  pulmonary  vessels. 
Under  these  circumstances,  the  fibrin  may  coagulate,  becoming 
adherent  to  the  tendinous  cords  and  fleshy  columns,  interfering 
with  the  action  of  the  tricuspid  valve,  obstructing  the  auriculo-ven- 
tricular orifice,  and  thus  prove  the  immediate  cause  of  death.  Or, 
if  there  exist  aortic  lesions  involving  obstruction  or  regurgitation, 
the  left  ventricle,  after  a  time,  reaches  the  limit  of  hypertrophic 
enlargement,  and  dilatation  predominates,  with  consequent  weak- 
ness, and  inability  to  expel  but  a  small  part  of  the  contents  of  this 
cavity.  The  same  result  may  take  place  here,  but  it  occurs  more 
infrequently  than  in  the  cavities  of  the   right   side.      Extrinsic 

'  The  prize  essay  hy  Dr.  Richardson  may  be  consulted  with  advantage  on  this 
subject. 


250      AFFECTIONS   INCIDENTAL    TO    OKGANIC    DISEASES. 

causes,  which  weaken  the  heart,  and  certain  states  of  the  blood 
favoring  coagulation,  will  contribute  to,  and  may  suffice  for  the 
occurrence  of  this  accident.  The  formation  of  coagula  may  lead 
rapidly  to  a  fatal  termination.  In  a  certain  proportion  of  the  in- 
stances of  sudden  death,  it  is  to  be  thus  explained.  In  other  cases, 
life  continues  for  some  time  with  an  aggravation  of  all  the  symp- 
toms referable  to  the  heart,  dating  from  the  epoch  when  coagula- 
tion took  place.  The  mechanism  of  the  formation  of  coagula,  under 
these  circumstances,  is  analogous  to  that  by  which  they  are  formed 
in  sacculated  aneurisms. 

The  symptoms  of  the  formation  of  coagula  in  cases  of  organic 
disease  of  the  heart  are  certainly  not  distinctive,  but,  taken  in  con- 
nection with  all  the  circumstances  in  the  case,  they  often  point  with 
much  significance  to  this  accident.  The  significance  consists  in  the 
sudden  and  great  increase  in  the  intensity  of  all  the  symptoms 
referable  to  the  heart,  under  circumstances  which  render  this  ex- 
planation reasonable,  and  when  the  striking  change  in  the  condition 
of  the  patient  is  not  to  be  otherwise  accounted  for.  The  reasoning 
is  by  exclusion  rather  than  by  positive  diagnostic  evidence.  The 
formation  of  coagula  is  to  be  strongly  suspected  if  a  person  known 
to  have  an  organic  affection  of  the  heart,  which  has  eventuated  in 
dilatation,  be  abruptly  seized  with  notable  increase  of  dyspnoea, 
amounting  to  orthopnoea,  and  persistent,  with  a  distressing  sense  of 
oppression  at  the  prascordia;  the  heart  becoming  irregular  and 
tumultuous ;  the  pulse  correspondingly  disordered,  extremely  fre- 
quent, and  feeble ;  and  the  more  remote  symptomatic  phenomena, 
such  as  lividity,  dropsical  effusion,  coldness  of  the  extremities, 
being  aggravated  in  proportion.  This  suspicion  is  resolved  into 
an  opinion  which  may  be  entertained  with  great  confidence,  if  a 
careful  examination  of  the  chest  reveals  no  intercurrent  pulmonary 
disease,  nor  a  superadded  cardiac  afiection  adequate  to  account  for 
the  remarkable  alteration  which  has  ensued.  An  acquaintance  with 
the  symptoms  and  condition  of  the  patient  prior  to  the  occurrence 
of  the  accident  is  important  with  reference  to  the  diagnosis.  If  the 
case  have  not  been  previously  under  observation,  the  practitioner  is 
not  so  well  prepared  to  estimate  properly  the  change  as  when  it 
takes  place  under  his  own  eyes.  He  can  neither  appreciate  its 
extent  nor  its  suddenness,  and  the  latter  is  an  essential  point  in 
the  diagnosis.  The  practicability  of  the  diagnosis  presupposes  that 
the  coagula  occasion  obstruction  to  the  circulation  in  consequence 
either  of  the  space  which  they  occupy,  their  situation  at  or  near 


FIBKINOUS    COAGULA    WITHIN    THE    HEAET.  251 

the  orifices,  or  their  interference  with  the  proper  play  of  the  valves. 
A  mass  of  fibrin,  of  considerable  size,  situated  in  the  auricular  ap- 
pendix, or  attached  at  the  apex  of  the  ventricle,  may  not  give  rise 
to  a  degree  of  disturbance  greater  than  seems  fairly  attributable  to 
the  organic  lesions,  the  existence  of  which  has  been  ascertained. 
So,  if  the  coagula  are  slowly  formed,  the  symptoms  are  gradually 
developed,  and  the  diagnosis,  under  these  circumstances,  is  imprac- 
ticable. 

Physical  signs  furnish  but  little  aid  in  the  diagnosis.  The  pre- 
sence of  coagula  may  occasion  an  endocardial  murmur,  but,  as  a 
rule,  it  is  wanting,  probably  in  consequence  of  the  enfeebled  action 
of  the  heart.  Moreover,  a  newly-developed  murmur,  produced 
within  a  ventricular,  or,  possibly,  an  auricular,  cavity,  can  hardly 
be  discriminated  from  pre-existing  murmurs  referable  to  the  valvu- 
lar lesions  which  are  present  in  the  great  majority  of  cases.  Theo- 
retically, either  the  tricuspid  or  the  mitral  valvular  element  of  the 
first  sound  would  be  expected  to  be  impaired  or  lost,  according  as 
the  coagulated  fibrin  may  impede  the  play  of  the  one  or  the  other 
of  the  auricular  ventricular  valves.  But  weakness  of  the  heart  suf- 
fices to  diminish  or  annul  the  first  sound.  In  short,  the  diagnostic 
points  in  cases  of  fibrinous  coagula  incidental  to  organic  disease  of 
the  heart  must,  in  general,  be  derived  mainly  from  the  symptomatic 
phenomena,  not  from  physical  signs. 

The  diagnosis  of  the  formation  of  coagula  in  other  pathological 
associations,  is  free  from  some  of  the  difficulties  incident  to  their 
occurrence  in  connection  with  disease  of  the  heart.  For  example, 
with  the  knowledge  of  the  fact  that  in  cases  of  pneumonia  termi- 
nating fatally  this  accident  is  apt  to  occur,  if,  in  the  progress  of 
that  disease,  the  impulse  of  the  heart  and  the  pulse  suddenly  be- 
come extremely  tumultuous,  frequent,  irregular,  and  accompanied 
by  a.  degree  of  dyspnoea  not  explicable  by  the  development  of 
inflammation  in  another  lobe,  or  any  new  condition  referable  to 
the  lungs,  the  grounds  for  suspecting  coagulation  within  the  heart 
may  be  stronger  than  in  some  of  the  instances  in  which  it  occurs 
in  cardiac  affections,  for  the  latter  may  have  already  induced  great 
weakness  and  disordered  action  of  the  heart,  with  corresponding 
disturbance  of  respiration,  etc.  The  change,  as  regards  the  symp- 
toms referable  to  the  heart,  is  not  so  striking  in  the  latter  case  as 
in  the  former,  and  other  explanations  than  the  formation  of  coagula 
are  less  available.  Moreover,  assuming  that,  in  the  case  of  pneu- 
monia, the  absence  of  previous  cardiac  disease  has  been  ascertained, 


252      AFFECTIONS    INCIDENTAL    TO    ORGANIC    DISEASES.  ' 

if  the  presence  of  a  coagulum  give  rise  to  an  endocardial  murmur, 
at  the  same  time  that  the  striking  symptoms  referable  to  the  heart 
occur,  this  constitutes  strong  evidence  of  the  nature  of  the  accident. 

The  prognosis  in  cases  in  which  the  symptoms  denote  the  forma- 
tion of  fibrinous  coagula  is  in  the  highest  degree  unfavorable.  If 
death  do  not  speedily  follow,  the  utmost  to  be  hoped  for  is  that  life 
may  be  prolonged  for  a  few  days  or  possibly  weeks.  There  are 
scarcely  any  chances  for  improvement,  and  none  for  recovery. 
Bouillaud  entertains  the  belief  that  the  coagula  are  sometimes  dis- 
solved and  disappear.  The  ground  for  such  a  belief  is  so  small  as 
to  render  it  excusable  to  conclude  that,  in  the  instances  in  which 
this  favorable  termination  has  been  supposed  to  take  place,  an 
error  of  diagnosis  was  committed.  Correctness  of  diagnosis,  in 
fact,  is  of  advantage  only  in  enabling  the  practitioner  to  decide 
that  a  fatal  result  is  inevitable.  As  incidental  to  organic  affections 
of  the  heart,  however,  it  is  to  be  borne  in  mind  that  in  most 
instances  the  condition  of  the  patient  prior  to  this  accident  was 
hopeless.  The  effect  of  the  latter,  in  general,  is  only  to  hasten  the 
period  of  relief  from  the  sufferings  incident  to  incurable  disease. 

As  regards  treatment,  it  follows  from  the  remarks  just  made 
that,  after  coagula  have  formed,  palliative  measures  are  alone  indi- 
cated. These  consist  of  remedies  to  relieve  dyspnoea  and  prascor- 
dial  distress,  stimulants  to  maintain  the  action  of  the  heart,  and 
revulsive  applications,  such  as  fomentations,  sinapisms,  and  stimu- 
lating pediluvia.  The  idea  of  giving  remedies  with  a  view  to 
dissolve  the  solidified  fibrin  is  absurd.  To  prevent  the  coagulation 
of  fibrin,  when  circumstances  are  present  under  which  it  may  be 
expected  to  occur,  is  legitimate,  and  may  be  an  important  object  of 
treatment.  This  object  involves,  in  the  first  place,  obviating  as  far 
as  possible  the  accumulation  of  blood  in  the  cavities  of  the  heart 
by  measures  which  have  been  already  considered  in  connection 
with  the  treatment  of  valvular  lesions.  Sedative  remedies,  pushed 
to  the  extent  of  retarding  and  weakening  unduly  the  muscular 
contractions  of  the  heart,  are  objectionable,  among  other  reasons, 
on  the  ground  that  they  may  favor  coagulation.  Digitalis  is  by 
some  writers  regarded  as  a  dangerous  remedy  on  this  ground  in 
cases  of  advanced  organic  or  other  disease  in  which  the  organ  is 
already  enfeebled.  This  remedy,  however,  is  unattended  by  dan- 
ger with  proper  care,  if  it  be  true  that  while  it  retards  the  move- 
ments of  the  heart,  it  does  not  diminish  the  muscular  power  of  the 
organ.     In  the  second  place,  it   is   not   improbable  that  certain 


POLYPI    OF   THE    HEAET.  253 

remedies  may  favor  the  solubility  of  fibrin,  and  in  this  way 
prevent  coagulation.  Various  alkaline  remedies  have  been  sup- 
posed to  have  this  effect.  If  it  be  true  that  the  fibrin  is  held  in 
solution  in  the  blood  by  the  presence  of  ammonia,  according  to  the 
late  researches  by  Dr.  Kichardson,  it  would  seem  to  be  a  rational 
inference  that  ammoniacal  remedies  must  be  the  most  efficient  in 
fulfilling  this  second  object  in  the  prophylactic  treatment. 


POLYPI  OF  THE   HEART. 


The  clots  and  fibrinous  coagula  which  have  been  considered, 
were  regarded,  as  already  stated,  by  the  older  pathologists  as  mor- 
bid growths  resembling  the  polypi  met  with  in  the  uterus,  nasal 
passages,  and  other  situations.  They  were  called  2^olypi  of  the 
heart,  and  the  term  polypoid  formations  is  still  very  generally 
applied,  to  them.  It  is  needless  to  say  that,  pathologically,  they 
bear  no  resemblance  to  polypi,  since  they  are  not  morbid  growths, 
and  never  become  organized.  They  cannot,  therefore,  with  pro- 
priety be  said  to  be  polypoid,  and  the  use  of  this  term  has  been 
designedly  avoided  in  the  foregoing  remarks.  Abnormal  produc- 
tions, however,  may  occur  within  the  cavities  of  the  heart,  which 
are  analogous  to  polypi  or  polypoid  growths.  Grisolle*  gives  the 
results  of  the  analyses  of  seven  cases,  which  he  states  to  be  all  the 
authentic  cases  on  record.^  In  nearly  all  these  cases  there  existed 
a  pedunculated  tumor  varying  in  size  from  a  pigeon's  egg  to  a 
hen's  egg ;  in  six  of  the  cases  contained  in  the  right,  and  in  one 
instance  in  the  left  auricle.  In  all  of  the  cases  in  which  the  point 
of  attachment  was  indicated,  it  was  at  or  near  the  foramen  ovale. 
In  four  cases  the  tumor  extended  through  the  auriculo -ventricular 
orifice  into  the  ventricle.  The  peduncle  was  formed  apparently 
by  the  endocardial  membrane  which  generally  extended  over  the 
tumor.  The  form  of  the  polypi  was  pyramidal,  and  they  presented 
in  some  instances  a  smooth,  and  in  other  instances  a  lobulated 

'  Traite  de  Pathologie  Interne,  1852,  tome  second,  p.  389, 

^  The  museum  of  the  Boston  Society  for  Medical  Improvement  contains  a  speci- 
men presenting  a  tumor  hanging  loose  in  the  cavitj  of  the  left  auricle,  supposed 
to  be  malignant  from  the  coexistence  of  malignant  disease  in  the  lung  and  about 
the  elbow.     Vide  printed  Catalogue,  1847,  p.  88. 


254      AFFECTIONS    IXCIDEXTAL    TO    ORGANIC    DISEASES. 

surface.  The  substance  of  the  tumors  varied  in  appearance.  In 
one  case  it  had  a  fleshy  aspect,  in  one  case  it  resembled  a  fungous 
growth,  and  in  two  cases  the  texture  was  fibrous.  In  every  case 
there  was  hypertrophy  of  the  auricle  and  the  corresponding  ven- 
tricle. 

The  formation  of  true  polypi  in  the  heart  differs  from  that  of 
clots  and  fibrinous  coagula  in  this,  viz.,  it  goes  on  slowly,  and  con- 
siderable time  must  be  required  for  the  growth  of  a  tumor  of  suffi- 
cient size  to  occasion  serious  inconvenience.  Hence,  the  symptoms 
are  developed  gradually  and  imperceptibly,  not  abruptly  as  in  cases 
of  coagula.  When  developed,  the  symptoms  denote  an  organic 
affection  of  the  heart,  without  pointing  to  the  existence  of  a  tumor. 
The  physical  signs,  as  well  as  symptoms,  are  not  distinctive  of  the 
nature  of  the  affection.  They  may  indicate  obstruction,  or  regurgi- 
tation, or  both,  associated  with  more  or  less  cardiac  enlargement. 
Taking  into  view  the  excessive  infrequency  of  these  growths,  their 
existence  can  hardly  be  suspected  from  the  phenomena  during  life. 

It  is  needless  to  consider  the  treatment.  The  fact  of  some  ob- 
scure cardiac  affection  being  determined,  the  indications  will  be 
derived  from  the  condition  of  the  heart  as  respects  enlargement, 
and  the  symptoms. 


ANGINA   PECTORIS. 


An  extremely  distressing  and  grave  affection,  occurring,  happily, 
in  a  very  small  proportion  of  cases  of  organic  disease  of  heart,  is 
commonly  known  by  the  name  of  angina  pectoris.'  This  name  was 
applied  to  the  affection  by  Dr.  Heberden,  who  was  the  first  to  give 
a  full  and  clear  description  of  it  in  1768.  The  affection  is  charac- 
terized by  paroxysms  of  intense  pain  emanating  from  the  neigh- 
borhood of  the  pr^ecordia,  extending  thence  in  various  directions, 
often  into  the  left  shoulder  and  down  the  arm,  accompanied  by 
indescribable  anguish,  a  sense  of  suffocation,  and  a  feeling  of  im- 
pending death.  These  are  symptoms  characteristic  of  the  affection 
in  a  severe  form.  The  prsecordial  pain  is  variously  described  by 
patients,  being  lancinating,  contusive,  lacerating,  burning,  or  con- 

'  ayx<"i  to  strangle. 


AXGIXA    PECTORIS.  255 

strictive.  Its  centre,  or  focus,  generally  appears  to  be  over  the 
heart,  to  the  left  of  the  sternum.  It  is  sometimes  most  intense 
beneath  the  sternum ;  and  Valleix  cites  two  instances  in  which  the 
greatest  intensity  was  referred  to  the  right  of  the  sternum.^  The 
pain  radiates,  as  it  were,  into  both  sides  of  the  chest,  into  the  back, 
extending,  as  already  stated,  often  into  the  left  upper  extremity, 
but  sometimes,  as  in  one  instance  under  my  observation,  into  both 
upper  extremities,  and  occasionally  into  one  or  both  lower  extremi- 
ties. Dr.  Hope  met  with  several  instances  in  which  it  pervaded  all 
the  extremities.  Not  uncommonly  it  ascends  to  the  neck  in  front 
or  behind,  and  I  have  met  with  an  instance  in  which  it  extended  to 
the  jaws  and  temples.  The  pain  in  the  upper  extremity  sometimes 
appears  to  end  abruptly  at  the  shoulder,  and  in  other  cases  at  the 
elbow.  I  have  known  it  to  be  felt  acutely  in  the  forearm,  and  not 
in  the  arm  or  shoulder.  ISTot  infrequently  it  seems  to  follow  the 
course  of  the  nerves,  and  is  felt  over  the  whole  affected  extremity, 
even  to  the  fingers.  The  pain  is  attended  by  a  feeling  of  numbness, 
or  as  if  the  limb  were  paralyzed.  Numbness  referred  to  the  testes 
is  mentioned  by  Dr.  Walshe  as  a  rare  concomitant.  Tenderness  to 
the  touch,  or  hypersesthesia  of  the  integument  over  the  situations 
in  which  the  pain  is  felt,  has  been  observed  in  some  cases,  especially 
in  females. 

The  affection  is  essentially  paroxysmal.  The  patient  is  seized 
suddenly,  often  when  in  motion,  and  the  paroxysm  has  been  re- 
peatedly noticed  to  occur  in  walking  up  an  acclivity,  after  a  meal, 
and  especially  against  a  strong  current  of  air.  Instant  and  com- 
plete rest  is  imperative.  He  seizes  hold  of  some  firm  support,  if 
any  be  at  hand,  or  he  finds  it  necessary  to  take  a  sitting  or  recum- 
bent posture,  which  he  does  with  great  caution,  and  remains  as 
immovable  as  possible  until  the  paroxysm  passes  off.  The  pain  is 
by  no  means  the  sole  element  of  the  distress.  The  sense  of  suffo- 
cation and  of  impending  dissolution  occasions  hardly  less  suffering. 
There  is,  in  addition,  often  a  feeling  of  anguish  which  patients  find 
it  impossible  to  describe.  Dyspncea  is  not  a  constant  element  of 
the  paroxysms.  It  may  be  present,  but  is  frequently  wanting. 
The  respiratory  movements  are  often  momentarily  suspended  or 
restrained  by  an  act  of  the  will,  from  fear  of  increasing  the  pain 
and  distress,  but  the  ability  to  expand  the  chest  and  breathe  regu- 
larly is  not  necessarily  impaired.     An  intelligent  patient  recently 

'  Guide  de  Medecine  pratique. 


256      AFFECTIONS   INCIDENTAL    TO    ORGANIC    DISEASES. 

under  my  observation,  who  was  subject  both  to  angina  and  pa- 
roxysms of  dyspnoea,  described  them  as  clearly  distinct  from  each 
other,  nor  were  the  two  liable  to  occur  at  the  same  time.    Not  infre- 
quently the  respirations  continue  unaffected  during  the  paroxysms 
of  angina,  and  they  are  rarely  more  than  moderately  accelerated. 
Palpitation  is  often  present.     It  is  rare  for  the  action  of  the  heart 
to  be  undisturbed,  certainly  if  the  paroxysms  are  severe.     Often 
the  heart  acts  with  great  violence,  seeming,  to  quote  the  language 
of  a  patient,  "as  if  it  would  leap  out  of  the  mouth."     It  is  fre- 
quently irregular  and  intermitting,  the  pulse  sometimes  indicating 
vigor,  and  in  other  instances  feebleness,  of  the  ventricular  contrac- 
tions.    The  pulse,  however,  has  been  observed  to  be  unnaturally 
slow  during  the  paroxysms.     The  countenance  is  pallid,  and  ex- 
presses great  anxiety  and  distress.    The  change  in  this  respect  may 
be  very  striking,  a  deathlike  complexion,  with  great  haggardness 
of  the  features,  suddenly  taking  the  place  of  an  appearance   of 
health.     Lividity  is  occasionally  observed.     The  surface  is  cold, 
and  frequently  bathed  in  perspiration.     The  faculties  of  the  mind 
remain  unaffected.     A  free  secretion  of  limpid  urine  takes  place  in 
some  cases.     The  reader  who  has  not  witnessed  a  severe  paroxysm, 
may  form  from  the  foregoing  account  some  idea  of  the  distressing 
nature  of  this  affection.    There  are  few,  if  any,  diseases  which  give 
rise  to  greater  suffering.     A  patient  who  experienced  the  excru- 
ciating torture  of  daily  attacks  for  several  months  before  he  found 
relief  in  death,  made  a  dying  request  that  I  should  examine  his 
body  post-mortem,  in  the  hope  that  something  might  be  thereby 
ascertained  which,  would  lead  to  the  means  of  relieving  others  in 
like  manner  afflicted ;  a  request  Avith  which  I  did  not  fail  to  comply. 
The  paroxysms  of  angina,  in  different  cases,  differ  much,  not  only 
in  severity,  but  in  their  frequency  of  recurrence,  their  duration,  etc. 
They  do  not  always  have  the  severe  character  which  has  been  por- 
trayed in  the  foregoing  sketch.    They  are  sometimes  comparatively 
mild.   The  affection  in  some  cases  commences  with  mild  parox3^sms, 
which  may  progressively  become  more  severe ;  but  in  other  cases 
the  first  attack  is  intensely  distressing.    Their  duration  is  extremely 
variable.     Often  they  last  only  for  a  few  moments,  but  in  some  of 
the  instances  which  have  fallen  under  my  observation,  the  suffering 
has  continued  for  several  hours.    The  cessation  of  the  paroxj^sm  is 
frequently  as  abrupt  as  the  commencement.      I  have  known  a 
laborer  to  be  attacked  repeatedly  while  at  work,  and,  resting  for  a 
few  moments  till  the  paroxysm  ceased,  at  once  resume  his  labor. 


ANGINA    PECTOEIS.  257 

In  some  instances,  however,  relief  is  gvadual.  There  exists  an 
equal  diversity,  in  different  cases,  as  respects  recurrence  of  the  pa- 
roxysms. They  may  recur  after  intervals  of  a  few  hours,  or  even 
moments;  or  days,  weeks,  months,  and  years  may  elapse  between 
successive  attacks.  The  paroxysms  are  apt  progressively  to  be- 
come more  and  more  frequent,  as  well  as  more  and  more  severe. 
Patients  sometimes  have  repetitions,  more  or  less  frequent,  during 
several  days  or  weeks,  and  a  respite  for  several  months  follows. 
The  affection  pursued  this  course  in  one  of  the  cases  which  I  have 
observed.  In  the  vast  majority  of  cases  in  which  a  paroxysm  has 
once  occurred,  other  attacks  follow  after  longer  or  shorter  intervals. 
Clinical  experience  furnishes  very  little  ground  for  encouraging 
patients  to  hope  for  future  exemption ;  on  the  contrary,  it  is  almost 
certain  that  the  affection  will  continue,  and  become  more  serious. 
I  have  met,  however,  with  one  instance  in  which  two  extremely 
severe  paroxysms  occurred,  the  interval  being  about  forty-eight 
hours,  and  each  paroxysm  lasting  from  three  to  four  hours,  in  a 
patient  aged  sixty-seven,  who  subsequently  never  had  a  recurrence, 
dying,  after  ten  or  twelve  years,  with  symptoms  of  cardiac  disease. 
The  paroxysms  of  angina  frequently  appear  to  be  induced  by 
some  exciting  cause,  such  as  ascending  an  elevation,  muscular  exer- 
tion of  any  kind,  mental  excitement,  etc.  But  in  many  instances 
they  occur  without  any  such  cause,  taking  place  in  the  night,  or 
when  the  person  affected  is  perfectly  at  rest  in  body  and  mind. 
When  they  recur  with  great  frequency,  slight  causes  seem  adequate 
to  determine  an  attack.  I  have  known  the  act  of  swallowing  solid 
food  sufficient,  so  that  the  patient  resisted  as  long  as  possible  the 
desire  to  take  nourishment.  In  the  same  case  the  paroxysms  often 
occurred  during  sleep,  appearing  to  the  patient  to  be  produced  in 
consequence  of  dreams.  On  account  of  this  liability,  he  hardly 
dared  to  sleep.  The  suffering  in  this  case  was  beyond  description. 
In  some  of  the  cases  which  I  have  observed,  the  paroxysms  occurred 
only  when  it  seemed  fair  to  refer  them  to  some  obvious  exciting 
cause.  In  another  case,  to  which  I  have  before  alluded,  the  parox- 
ysms always  occurred,  as  it  were,  spontaneously,  and  causes  which 
provoked  severe  attacks  of  dyspnoea,  or  cardiac  asthma,  never 
occasioned  angina.  Cardiac  asthma,  according  to  Dr.  Stokes,  is 
frequently  confounded  by  practitioners  with  angina,  but,  certainly, 
these  two  incidental  affections  are  sufficiently  distinct,  although 
they  may  both  occur  in  the  same  case,  and,  perhaps,  simultaneously 
in  some  instances. 
17 


258      AFFECTIONS    INCIDENTAL    TO    ORGANIC    DISEASES. 

We  come  now  to  inquire  what  is  the  pathological  character  of  this 
affection,  and  what  are  its  pathological  relations.  The  points  in- 
volved in  these  inquiries  have  been  much  discussed,  and  pathologists 
are  by  no  means  agreed  respecting  them.  Without  canvassing  dif- 
ferent hypotheses,  it  seems  to  me  sufficiently  clear  that  the  afiection 
must  be  considered  as  a  form  of  neuralgia,  or,  at  all  events,  that  the 
painful  element  in  the  paroxysms  is  essentially  neuralgic.  The  va- 
rious kinds  of  pain  are  those  which  belong  to  neuralgic  affections. 
The  radiation  of  the  pain  in  different  directions  is  characteristic  of 
the  latter.  Moreover,  in  some  instances  the  pain  distinctly  follows  the 
course  of  the  nerves  of  the  extremities.  The  identity  is  further 
shown  by  the  abruptness  of  the  attack,  the  suddenness  with  which  the 
paroxysm  frequently  ends,  and  the  completeness  with  which  it  dis- 
appears, leaving  no  trace  of  the  affection  except  a  certain  amount 
of  soreness  and  prostration.  Dr.  Heberden  and  others  have  attri- 
buted the  pain  to  spasm  ;  but  a  spasmodic  contraction  of  the  heart 
sufficient  to  occasion  such  prolonged  as  well  as  intense  suffering 
would  be  incompatible  with  life.  Disturbance  of  the  muscular 
action  of  the  heart  is  not,  as  a  rule,  proportionate  to  the  amount  of 
pain.  The  pain  in  some  instances  is  extreme,  while  the  movements 
of  the  heart  are  but  little  disturbed.  The  violent  and  disordered 
action  which  undoubtedly  constitutes  an  element  of  the  paroxysms 
of  angina,  may  be  said  to  be  spasmodic,  but  in  the  same  sense  that 
functional  disturbance,  or  palpitation,  occurring  under  other  cir- 
cumstances, involves  spasm.  That  this  element  is  distinct  from  the 
painful  element,  is  shown  by  the  fact  that  functional  disturbance 
of  the  heart,  be  it  ever  so  great,  is  rarely  accompanied  by  much 
pain.  Neuralgic  pain,  and  disturbed  muscular  action  of  the  heart, 
are  thus  two  elements  of  angina,  which  although,  associated,  are 
pathologically  distinct.  The  term  cardialgia^  were  it  not  appropriated 
to  denote  pain  supposed  to  be  referable  to  the  cardiac  extremity  of 
the  stomach,  would  be  a  more  appropriate  name  than  angina,  for 
the  affection  under  consideration.  This  term  is  applied  by  Forget 
to  pain  seated  in  the  heart.'' 

As  regards  the  pathological  relations  of  angina,  it  involves,  in 
general  terms,  the  existence  of  some  organic  affection  of  the  heart. 
If  this  rule  be  not  invariable,  the  exceptions  are  so  few  that  they 
may  practically  be  disregarded.  Of  45  cases  in  which  the  post- 
mortem appearances  were  recorded,  collected  from  various  sources, 

'  Op.  cit. 


ANGINA    PECTOEIS.  259 

and  analyzed  by  Sir  John  Forbes  in  an  essay  published  fifteen 
years  ago,'  tbe  heart  was  reported  to  be  unaffected  in  two  instances 
only  ;  and  in  view  of  the  fact  that  certain  morbid  conditions  of  the 
heart  have  not  been  fully  recognized  until  within  late  years,  it 
must  be  considered  as  highly  probable  that  in  the  two  excepted 
instances,  structural  lesions  may  have  been  overlooked.  Assuming 
the  constancy  of  organic  disease,  does  angina  involve  the  existence 
of  any  particular  kind  of  lesion  ?  In  answer  to  this  question,  dis- 
sections show  that  the  lesions  found  in  different  cases  are  not 
uniform,  and  that  they  do  not  agree,  invariably,  in  any  one  or  more 
appreciable  morbid  alterations.  The  heart  may  or  may  not  be 
enlarged.  Valvular  lesions  are  either  present  or  wanting.  Calcifi- 
cation of  the  coronary  arteries  is  the  only  appreciable  lesion  in 
some  cases,  but  in  other  cases  these  arteries  have  been  found  to  be 
entirely  healthy  and  free  from  obstruction.  Fatty  degeneration 
and  softening  are  sometimes  observed,  but  by  no  means  as  a  rule. 
In  the  two  most  severe  cases  that  have  fallen  under  my  observation, 
death  being  in  both  due  to  the  angina,  the  substance  of  the  heart 
was  firm,  presenting  no  appearance  of  fatty  change.  In  short,  angina 
has  no  settled  anatomical  character  beyond  the  fact  that  it  is  inci- 
dental to  organic  disease  of  some  kind.  The  affection  occurs  oftener 
in  connection  with  lesions  seated  in  the  aorta  than  elsewhere. 
Aortic  lesions  were  present  in  24  of  39  cases  analyzed  by  Dr.  Forbes. 
Judging  from  physical  signs,  as  well  as  the  results  of  dissection,  in 
the  cases  that  have  fallen  under  my  observation,  I  should  say  that 
lesions  of  the  aorta  or  the  aortic  orifice  are  present  in  much  the 
larger  proportion  of  instances.  But  that  these  lesions  are  not 
essential  is  sufficiently  established.  Doubtless  some  one  or  more 
particular  abnormal  conditions  are  common  to  all  the  cases  of 
organic  disease  of  the  heart  in  which  angina  occurs.  Logically  con- 
sidered, this  is  certainly  more  than  probable.  But  the  nature  and 
seat  of  these  conditions  are  yet  to  be  determined.  With  our  pre- 
sent knowledge  we  have  nothing  but  conjectures  on  this  point. 
There  will  be  no  advantage,  in  a  practical  point  of  view,  in  con- 
sidering these.  I  will  simply  remark  that  the  hypothesis  which 
attributes  the  occurrence  of  angina  to  simple  weakness  of  the  heart, 
seems  to  me  to  be  without  any  foundation.  Not  only  is  the  heart 
weakened  in  a  host  of  cases  of  dilatation  and  fatty  degeneration, 

'  Cyclopaedia  of  practical  medicine,  art.  Angina  Pectoris.  I  include  in  the  num- 
ber of  cases  of  cardiac  disease,  those  (four  iu  number)  in  which  obesity  of  the 
heart  only  existed. 


260      AFFECTIONS    IXCIDEXTAL    TO    ORGAXIC    DISEASES. 

without  the  occurrence  of  angina,  but  weakness  by  no  means  exists 
uniformly  in  the  cases  in  which  angina  occurs.  In  several  of  the 
instances  which  have  come  under  my  observation,  a  paroxysm  of 
angina  was  the  first  event  to  denote  the  existence  of  cardiac  disease, 
and  patients  continue  for  a  long  time  to  take  active  exercise,  per- 
forming, for  example,  severe  manual  labor,  without  any  inconveni- 
ence save  from  the  recurrence  of  angina.  In  the  two  severest  cases 
that  I  have  observed,  the  patients,  even  a  few  weeks  before  death, 
were  confident  of  their  ability  still  to  work,  if  the  frequent  attacks 
could  be  prevented.  These  facts  are  inconsistent  with  much  weak- 
ness of  the  heart.  Moreover,  the  physical  signs  in  certain  cases, 
for  a  longer  or  shorter  period,  show  that  the  heart  acts  with  vigor, 
and,  in  some  instances,  with  the  abnormal  power  incident  to  hyper- 
trophy. 

According  due  weight  to  the  facts  just  presented,  angina  pectoris 
is  to  be  considered  as  a  neuropathic  affection,  incidental  exclusively 
to  organic  afiections  of  the  heart,  and  dependent  on  conditions 
pertaining  to  the  different  forms  of  cardiac  lesions,  which,  it  must 
be  confessed,  have  not,  as  yet,  been  ascertained.  With  this  view 
of  its  pathology,  is  it  properly  a  distinct  affection,  or,  in  other 
words,  an  individual  disease?  Some  writers  are  of  opinion  that  it 
should  be  regarded  merely  in  the  light  of  a  symptom.^  It  is 
symptomatic  of  cardiac  disease,  but  not  of  any  one  of  the  varied 
lesions  to  which  the  heart  is  subject.  It  embraces  a  group  of 
phenomena  which  are  striking  and  distinctive.  It  derives  from  its 
peculiar  features  a  strongly -marked  individuality.  It  places  the 
patient  in  great  danger,  irrespective  of  the  lesions  with  which  it  is 
connected,  so  far  as  the  latter  are  appreciable.  It  has,  thus,  all  the 
attributes  of  a  distinct  affection,  exclusive  of  the  fact  that  it  is 
secondary,  {.  e.,  dependent  on  pre-existing  disease,  and  this  is  true 
of  not  a  few  individual  diseases. 

Ano-ina  pectoris  is  a  rare  affection.  Of  over  one  hundred  and 
fifty  cases  of  organic  disease  of  the  heart,  as  evidenced  either  by 
the  results  of  examination  after  death  or  well-marked  physical 
signs,  the  histories  of  which  are  before  me,  this  complication 
existed  in  seven  onl3^  This  infrequency  shows  that  it  depends  on 
conditions  which,  so  far  from  being  associated  with  structural 
lesions  as  a  rule,  are  quite  exceptional.  Its  connection  with 
organic  disease  of  the  heart  might  be  considered   as   merely  a 

'  e.  (/.  Bellingham,  op.  cit. 


ANGINA    PECTORIS.  261 

coincidence,  were  it  not  that  it  occurs  only  in  this  connection. 
With  reference  to  the  constant  coexistence  of  organic  disease,  some 
writers,  it  should  be  remarked,  hold  to  the  opinion  that  the  affec- 
tion may  occur  independently  of  any  cardiac  lesions.  The  rare 
instances,  reported  many  years  ago,  in  which  the  heart  was  declared 
to  be  free  from  disease,  have  already  been  explained  by  supposing 
that  abnormal  appearances  which  had  not  then  been  studied  were 
overlooked.  Another  source  of  error  is  in  confounding  with  true 
angina  certain  neuralgic  affections  which  simulate  some  of  its  phe- 
nomena. In  certain  cases  of  hysteria,  for  example,  pain  is  referred 
to  the  prtecordia,  radiating,  perhaps,  in  various  directions,  possibly 
extending  to  the  left  shoulder  and  arm,  and  accompanied  by  palpi- 
tation, but  without  the  signs  of  organic  disease.  These  are  aptly 
styled  by  Dr.  Walshe  cases  of  pseudo-angina.  They  bear  but  a 
remote  resemblance  to  well-marked  cases  of  angina  associated  with 
cardiac  lesions,  and  it  seems  warrantable,  with  our  present  know- 
ledge, to  limit  the  application  of  the  term  angina  to  the  latter. 

The  affection  is  observed  much  oftener  in  males  than  in  females. 
Of  88  cases  analyzed  with  reference  to  this  point  by  Dr.  Forbes,  80 
were  males  and  8  females.  This  immense  disproportion  shows  that 
a  very  decided  causative  influence  pertains  to  sex.  A  similar 
influence  belongs  to  age.  Of  these  88  cases,  in  72  the  age  exceeded 
fifty  years.  The  rule  with  respect  to  sex,  as  well  as  age,  however, 
it  is  to  be  borne  in  mind,  is  not  without  exceptions.  I  have  met 
with  the  affection  well  marked  in  a  female  of  twenty  years  of  age, 
who  subsequently  died  suddenly  during  an  attack.  It  has  been 
supposed  to  occur  oftener  in  the  higher  than  in  the  lower  walks  of 
life,  but  statistical  data  for  this  opinion  are  wanting. 

It  is  a  yerj  serious  affection,  not  only  in  consequence  of  the 
suffering  which  it  occasions,  and  as  denoting  an  organic  affection 
of  the  heart,  but,  intrinsically,  it  involves  great  danger.  In  a  large 
proportion  of  cases,  death  occurs  suddenly,  probably  from  arrest  of 
the  heart's  action  either  by  spasm  or  paralysis.  This  may  take 
place  in  one  of  the  early  paroxysms.  Instances  of  this  kind  are 
given  by  Dr.  Latham.'  But  generally  the  paroxysms,  becoming 
progressively  more  severe,  recur  with  more  and  more  frequency, 
and  the  fatal  result  is  preceded  by  a  period  of  intense  suffering, 
varying  greatly  in  duration  in  different  cases.  In  many  of  these 
cases,  the  organic  lesions,  irrespective  of  the  angina,  are  not  such 

'  Lectures  on  Diseases  of  the  Heart,  Am.  ed.,  1847,  p.  339. 


262      AFFECTIONS    IXCIDEXTAL    TO    ORGANIC    DISEASES. 

as  to  be  incompatible  with  a  much  longer  duration  of  life.  The 
complication  of  angina,  therefore,  in  cases  of  cardiac  disease,  adds 
greatly  to  the  gravity  of  the  prognosis.  It  is,  however,  to  be  borne 
in  mind  that  a  patient  may  experience  one  or  more  severe  attacks 
of  this  affection  without  further  recurrence  of  the  paroxysms.  I 
have  already  referred  to  an  instance  of  this  kind  which  has 
occurred  under  my  observation.  There  is  some  ground  for  hope, 
therefore,  that  the  affection  will  not  continue;  but,  it  must  be  con- 
fessed, the  chances  against  a  favorable  termination  preponderate  so 
vastly  that  such  a  hope  is  truly  a  forlorn  one.  Few  affections  are 
more  indeterminate  as  regards  duration  than  this.  It  may  destroy 
life  quickly,  or  after  a  lapse  of  time  varying  from  a  few  weeks  to 
many  years. 

The  diagnosis  of  angina  pectoris  is,  in  general,  easily  made,  pro- 
vided the  practitioner  have  a  clear  idea  of  its  distinctive  features. 
Its  paroxysmal  character,  the  attack  generally  being  remarkably 
abrupt,  and  often  ending  as  abruptly ;  the  brief  duration,  in  most 
instances,  of  the  parox3^sms;  the  intensity  of  the  neuralgic  pain,  and 
its  radiation  in  diSerent  directions,  in  most  instances  extending  to 
the  left  shoulder  and  arm ;  the  sense  of  suffocation ;  the  feeling  of 
approaching  death;  the  indescribable  anguish;  the  pallor,  anxiety, 
and  apprehension  depicted  in  the  countenance — these  are  diagnostic 
characters  which,  in  well-marked  examples,  leave  no  room  for  doubt 
as  to  the  nature  of  the  affection.  Paroxysms  of  dyspnoea  or  cardiac 
asthma,  which  are  apt  to  occur  in  the  progress  of  diseases  of  the 
heart,  present  points  of  difference  so  obvious  that  they  need  never 
be  mistaken  for  paroxysms  of  angina.  Their  most  prominent  and 
distinctive  feature,  as  the  name  dyspncsa  implies,  is  difficulty  of 
breathing.  The  sense  of  the  want  of  breath  is  the  chief  source  of 
suffering.  The  efforts  of  breathing  are  labored.  The  patient,  in- 
stead of  remaining  perfectly  quiet,  is  generally  restless,  frequently 
changing  his  position  with  the  hope  of  finding  relief.  This  diffi- 
culty of  respiration  does  not  belong  to  the  history  of  angina.  In  the 
paroxysms  of  the  latter  the  breathing  is  never  extremely  labored, 
and  the  patient  often  restrains  voluntarily  the  respiratory  move- 
ments, for  fear  of  increasing  his  distress  and  sense  of  danger.  Par- 
oxysms of  cardiac  asthma  rarely  occur  with  the  same  abruptness 
as  those  of  angina ;  nor  do  they  end  abruptly ;  and  they  are,  as  a 
rule,  of  much  longer  duration.  They  are  rarely  attended  by  acute 
pain.  They  are  not  characterized  by  that  intense,  undefinable  an- 
guish and  feeling  of  approaching  death  which  distinguish  an  attack 


ANGINA    PECTORIS.  263 

of  angina.  A  patient  suffering  from  dyspnoea,  however  intense, 
looks  forward  to  relief  and  comparative  comfort.  A  patient  at- 
tacked severely  with  angina  feels  that  he  is  momentarily  in  danger 
of  death,  and  that,  were  the  paroxysm  to  continue,  he  must  inevita- 
bly die.  In  short,  if  these  two  affections  are  sometimes  confounded, 
it  is  from  inattention  to  the  points  involved  in  the  differential 
diagnosis.  It  is  not  impossible,  however,  as  already  stated,  for 
paroxysms  of  angina  and  of  dyspnoea  to  occur  in  combination. 

It  is  somewhat  less  easy  to  discriminate  between  true  angina  and 
certain  neuralgic  pains  occurring  under  circumstances  which  cause 
them  to  simulate,  to  some  extent,  paroxysms  of  the  former.  In- 
stances, however,  in  which  there  is  much  real  difficulty  must  be 
very  rare.  The  cases  of  pseudo-angina,  to  which  reference  has 
been  already  made,  are  observed  in  connection  with  hysteria,  inter- 
costal neuralgia,  dyspepsia,  ansemia,  occasionally  gout,  etc.  They 
are  characterized  by  pain,  more  or  less  severe,  in  the  neighborhood 
of  the  prgecordia,  extending  thence  in  various  directions,  associated 
with  functional  disturbance  of  the  heart's  action,  and  the  mental 
uneasiness  and  apprehension  which  the  latter  almost  invariably 
occasions.  These  cases,  exclusive  of  gouty  subjects,  occur,  as  a 
rule,  prior  to  the  age  when  persons  are  subject  to  angina.  They 
are  most  apt  to  be  met  with  among  the  young,  and  perhaps  quite 
as  often  among  females  as  among  males.  The  acuteness  of  pain 
which  characterizes  attacks  of  angina,  the  anguish,  and  the  sense 
of  dying,  are  wanting,  or,  if  the  latter  be  present,  it  proceeds  from 
the  vague  fear  excited  by  unusual  sensations,  and  does  not  consist  in 
a  feeling  so  intense  and  defined  that  it  cannot  be  resisted.  Pseudo- 
angina,  moreover,  lacks  the  abruptness  of  the  beginning  and  ending 
of  the  paroxysms,  as  well  as  the  brief  duration,  which  characterize 
true  angina  in  the  great  majority  of  cases.  The  associated  disorders 
are  different.  Persons  affected  with  pseudo-angina  are  hysterical, 
anaemic,  dyspeptic,  etc.,  and  the  nervous  system  is  manifestly  dis- 
ordered. On  the  other  hand,  persons  are  often  attacked  with  true 
angina  when  apparently  in  good  health,  and,  at  all  events,  the  dis- 
orders just  referred  to  are  rarely  found  associated  with  it.  The 
coexistence  of  organic  disease  of  the  heart  is  to  be  considered.  In 
most  instances  of  angina  pectoris,  cardiac  lesions  are  determinable 
by  physical  signs ;  and,  assuming,  as  has  been  done,  that  the  affec- 
tion always  involves  structural  lesions  of  some  kind,  this  is  a  point 
entitled  to  weight  in  the  diagnosis.  In  cases  of  true  angina  we 
may  expect  to  find,  on  exploring  the  chest,  evidence  of  organic  dis- 


264      AFFECTIONS    INCIDENTAL    TO    ORGANIC    DISEASES. 

ease  of  the  heart,  and,  in  the  majority  of  cases,  signs  of  aortic  lesions ; 
in  cases  of  simulated  angina  we  may  expect  to  find  only  functional 
disturbance  of  the  organ.  If  the  pain  which  bears  some  resem- 
blance to  that  of  angina  be  due  to  intercostal  neuralgia,  the  latter 
affection  is  determined  by  finding  tenderness  on  pressure  limited  to 
circumscribed  spaces,  by  the  side  of  the  spinous  processes  of  the 
vertebrae  behind,  in  the  intercostal  spaces  on  the  lateral  surface  of 
the  chest,  and  near  the  median  line  in  front,  tenderness  at  these 
points  being  diagnostic  of  that  affection.  Finally,  the  question  as 
regards  the  differential  diagnosis  between  true  and  false  angina  can 
only  arise  when,  if  true  angina  be  present,  it  is  remarkably  mild, 
and  the  instances  in  which  this  affection  is  not  severe  are  very  rare 
exceptions  to  a  general  rule. 

Neuralgic  pain  is  sometimes  incidental  to  the  various  forms  of 
organic  lesion  of  the  heart,  without  constituting  angina  pectoris. 
As  a  symptom  of  cardiac  lesions,  exclusive  of  angina,  it  is  rarely 
present  in  a  marked  degree,  and  often  wanting.  Pain  may  be  due 
to  the  coincidence  of  intercostal  neuralgia,  but  in  some  instances  it 
is  evidently  seated  within  the  chest.  Aside  from  other  points,  the 
absence  of  the  strongly- marked  paroxysmal  character  of  angina 
suffices  for  the  discrimination.  There  is  no  evidence  that  the  exist- 
ence of  pain,  or  an  occasional  symptom  of  organic  disease  of  the 
heart,  denotes  greater  liability  to  paroxysms  of  angina  than  if  this 
symptom  were  not  present. 

The  treatment  of  angina  pectoris  embraces,  1st.  The  means  to  be 
employed  to  diminish  the  severity  and  shorten  the  duration  of  the 
paroxysms;  and,  2d.  Measures  in  the  intervals  to  postpone  or  pre- 
vent the  recurrence  of  the  paroxysms. 

The  severity  of  the  pain  during  the  attack,  and  its  neuralgic 
character,  point  to  the  propriety  of  opium;  and  clinical  experience 
shows  that  this  remedy  is  more  efficient  than  any  other,  in  afford- 
ing relief,  and  bringing  the  paroxysm  to  a  close.  It  is  to  be  given 
in  doses  proportionate  to  the  amount  of  suffering,-  and  repeated 
after  short  intervals  if  the  objects  be  not  attained.  The  form  of 
opiate  selected  should  have  reference  to  a  prompt  effect.  Lauda- 
num, the  black  drop,  or  an  aqueous  solution  are  preferable  to  the 
powder  or  solid  gum,  on  account  of  the  more  speedy  action  of  the 
former ;  but  the  salts  of  morphia  are  still  more  eligible  in  conse- 
quence of  the  ease  with  which  they  are  given,  and  the  greater 
certainty  of  their  being  retained.  A  convenient  mode  of  adminis- 
tration is  to  place  a  grain  upon  the  tongue.     The  succedanea  of 


ANGINA    PECTORIS.  265 

opium,  such  as  belladonna,  hjoscjamus,  etc.,  are  not  sufficiently 
effective.  They  may  be  employed,  however,  when  the  paroxysms 
recur  repeatedly  during  the  day,  and  it  is  not  deemed  judicious  to 
continue  to  prescribe  opium  freely.  Diffusible  stimulants  are  to  be 
given  at  short  intervals.  Brandy,  or  other  kinds  of  spirit,  may  be 
employed ;  also  the  ethereal  preparations  and  the  carbonate  of  am- 
monia. Eevulsive  applications  which  act  quickly,  are  indicated, 
viz.,  sinapisms,  dry  cupping,  vesication  with  strong  aqua  ammonia, 
hot  fomentations,  and  stimulating  pediluvia.  These  several  means 
are  to  be  combined  as  convenience  and  the  judgment  of  the  prac- 
titioner may  dictate  in  individual  cases.  The  unexpected  occur- 
rence of  the  paroxysms  and  their  brief  duration,  frequently  render 
it  impracticable  to  obtain  medical  aid  before  the  attack  has  passed 
off.  It  is  therefore  important  for  the  physician  to  give  directions 
concerning  the  course  to  be  pursued,  in  his  absence,  in  the  event 
of  a  recurrence  of  the  paroxysms — an  event  to  be  expected,  sooner 
or  later,  after  an  attack  has  been  once  experienced.  Efficient 
treatment  may  often  accomplish  much  toward  lessening  the  inten- 
sity, and  perhaps  the  continuance  of  paroxysms  in  certain  cases. 
But  when  the  liability  to  their  recurrence  is  such  that  they  succeed 
each  other  after  brief  intervals,  and  are  produced  by  slight  causes, 
palliative  measures,  which  unhappily  are  all  that  can  be  resorted 
to,  succeed  but  imperfectly.  I  have  known  the  inhalation  of 
chloroform  to  be  employed  in  one  case  of  this  description,  the 
severest  case  that  has  come  under  my  observation,  with  marked 
relief;  and,  indeed,  in  that  case,  this  after  a  time  was  the  only  pal- 
liative that  could  be  relied  upon. 

Under  the  head  of  '  measures  to  postpone  or  prevent  the  recur- 
rence of  the  paroxysms,'  little  is  to  be  said.  Rational  treatment 
based  on  knowledge  of  the  particular  morbid  condition  or  conditions 
involved  in  cardiac  lesions,  on  which  the  affection  is  immediately 
dependent,  cannot  be  laid  down ;  for  this  knowledge  is  not  yet 
acquired.  Nor  has  clinical  experience  led  to  the  discovery  of  the 
means  of  striking  at  the  pathological  root  of  the  affection.  There 
is  no  special  medication  to  be  pursued  in  cases  of  angina,  with  the 
hope  of  effecting  a  cure ;  and  it  is  doubtful  if  any  remedies  exert 
a  positive  influence  in  lengthening  the  period  of  exemption  from 
recurring  attacks.  Owing  to  the  variableness  of  the  intervals  be- 
tween the  paroxysms,  the  latter  effect  may  be  imputed  to  remedies, 
when  a  protracted  respite  occurs  merely  as  a  coincidence.  In  a 
case  in  which  the  paroxysms  had  for  some  time  recurred  almost 


266      AFFECTIONS    INCIDENTAL    TO    ORGANIC    DISEASES. 

daily,  I  was  led  to  prescribe  digitalis  and  hyoscyamus,  whicli  were 
taken  in  doses  sufficient  to  afiect  the  pulse  distinctly  and  obscure 
the  vision.  The  patient  was  free  from  the  affection  for  three  weeks. 
He  imagined  that  he  was  cured,  and  was  greatly  elated.  The  pa- 
roxysms, however,  returned,  becoming  more  frequent  and  severe, 
and  the  case  ended  fatally  in  a  few  months.  Here  was  apparently 
a  temporary  suspension  of  the  malady  as  a  result  of  certain  reme- 
dies ;  but  it  is  perhaps  more  reasonable  to  infer  from  the  inefficacy 
of  these  remedies  in  other  cases,  that  the  prolonged  interval  after 
their  use  in  this  instance,  was  merely  a  sequence,  not  a  consequence. 
The  treatment,  after  an  attack  of  angina  has  occurred,  with  a 
view  to  postpone  or  prevent  the  recurrence  of  the  paroxysms, 
resolves  itself  into,  1st.  That  indicated  by  the  existing  cardiac  dis- 
ease; and,  2d.  Avoiding,  as  far  as  practicable,  all  exciting  causes. 
Certain  affections  of  the  heart  are  always  present,  the  existence  of 
which  was,  perhaps,  not  known  prior  to  the  attack  of  angina.  The 
nature  and  extent  of  these  affections  in  different  cases  are  to  be 
determined  as  fully  as  possible  with  our  present  means  of  investi- 
gation, and  that  treatment  pursued  which  would  be  indicated  had 
the  angina  not  occurred.  It  may  reasonably  be  presumed  that  the 
treatment  which  is  most  judicious,  in  view  of  the  lesions  with 
which  the  heart  is  affected,  will  be  likely  to  prove,  in  a  greater  or 
less  degree,  useful  with  reference  to  the  recurrence  of  the  paroxysms 
of  angina.  The  indications  falling  under  this  head  have  already 
been  considered  in  treating  of  the  different  forms  of  organic  dis- 
ease of  the  heart  in  previous  chapters.  The  exciting  causes  to  be 
avoided  are  those  which  experience  shows  are  likely  to  occasion 
recurrence  of  the  paroxysms.  Strong  mental  excitement,  violent 
muscular  exercise  of  any  kind,  and  especially  walking  rapidly,  or 
ascending  an  acclivity  against  the  wind,  excesses  in  eating  or 
drinking,  etc.,  have  been  observed  to  bring  on  an  attack.  By 
scrupulously  avoiding  these  and  other  exciting  causes,  which  are 
peculiar  to  the  individual  experience  of  persons  affected,  it  is  highly 
probable  that  paroxysms  may  be  warded  off  which  would  other- 
wise have  occurred.  Important,  however,  as  is  this  part  of  the 
treatment,  its  effect  is  limited.  Paroxysms  often  occur  when  they 
are  not  referable  to  any  exciting  cause.  And  when  thus  referable, 
it  is  probable  that  often  the  exciting  cause  (as  the  name  implies) 
only  determines  the  particular  moment  when  the  paroxysm  takes 
place,  anticipating  somewhat  the  time  when  it  would  have  occurred 
spontaneously. 


ENLARGEMENT    OF    THYROID    BODY.  267 


ENLARGEMENT  OF  THE  THYROID  BODY   AND  PROMINENCE 

OF  THE  EYES. 


The  occurrence  of  enlargement  of  the  thyroid  body  and  promi- 
nence of  the  eyes,  in  certain  cases  of  cardiac  disease,  may  be 
conveniently  noticed  in  the  present  connection,  although,  as  will 
presently  appear,  it  is  by  no  means  certain  that  these  events 
necessarily  involve  the  existence  of  any  organic  affection,  and, 
indeed,  that  they  depend  on  an  abnormal  state  of  the  heart,  cannot 
perhaps  be  considered  as  conclusively  established.  It  is  only 
within  late  years  that  the  attention  of  clinical  observers  has  been 
directed  to  these  events,  as  connected  with  cardiac  disease.  The 
coincidence  of  enlargement  of  the  thyroid  body  with  affections  of 
the  heart  was  observed  by  Dr.  Parry  in  seven  cases.*  A  few 
instances  had  previously  been  reported.  Subsequently^  Dr.  Graves 
dwelt  upon  this  coincidence  in  his  Lectures  on  Clinical  Medicine^ 
published  in  1835,  giving  some  cases  that  had  fallen  under  his 
observation.  Still  more  recently,  the  coexistence  of  prominence  of 
the  eyes,  together  with  enlargement  of  the  thyroid  body,  has 
attracted  attention.  Cases  have  been  reported  by  Dr.  McDonnell 
and  Sir  Henry  Marsh,  of  Dublin,  and  by  Dr.  Stokes.  The  latter, 
in  his  late  work  on  the  Diseases  of  the  Heart  and  the  Aorta,  devotes 
considerable  space  to  the  consideration  of  the  subject.  In  our  own 
country.  Dr.  Isaac  E.  Taylor  has  contributed  an  elaborate  paper, 
containing  an  account  of  two  cases  which  he  has  himself  observed.* 
Dr.  Begbie,  of  Edinburgh,  and  Eobert  Taylor,  Esq.,  of  London, 
have  also  reported  cases.  The  latter  gives  the  details  of  four  cases 
which  have  fallen  under  his  own  observation,  and  an  analysis,  with 
regard  to  certain '  points,  of  twenty  cases  collected  from  various 
sources.' 

The  enlargement  of  the  thyroid  body  is  variable  in  degree,  being 
considerable  in  some  instances,  but  never  so  great  as  is  often  seen 

'  "  Collections  from  the  unpublished  Medical  Writings  of  the  late  Caleb  Hilliard 
Parry,  M.  D.,"  London,  1825. 

2  New  York  Medical  Times,  vol.  ii.,  No.  3,  December,  1852.  Accounts  of  two 
cases,  with  remarks,  and  references  to  the  literature  of  the  subject,  by  Prof.  H.  J. 
Bigelow,  Dr.  Morland,  and  Dr.  John  S.  Flint,  are  contained  in  an  article  which  has 
appeared,  since  the  printing  of  this  work  has  been  commenced,  in  the  Boston  Med. 
and  Surg.  Journal,  vol.  Ixi.  No.  2,  August  11,  1859. 

*  London  Medical  Times  and  Gazette,  May  24,  1856,  and  the  American  Journal 
of  Medical  Sciences,  July,  1856,  page  258. 


268      AFFECTIONS    INCIDENTAL    TO    OKGANIC    DISEASES, 

in  the  ordinary  form  of  bronchocele  or  goitre.  According  to  Dr. 
Graves,  the  limited  extent  of  the  enlargement  is  a  point  distinctive 
of  its  connection  with  an  abnormal  condition  of  the  heart.  Both 
lobes  of  the  thyroid  body  may  be  affected  equally,  or  the  size  of 
one  lobe  may  be  disproportionately  increased.  Having  attained  to 
a  certain  bulk,  the  enlargement  ceases  to  be  progressive,  and  the 
swelling  remains,  temporarily  or  permanently,  in  a  stationary  con- 
dition. Its  size  has  been  observed,  however,  to  fluctuate  between 
certain  limits,  varying  with  the  action  of  the  heart.  A  strong 
arterial  pulsation  is  felt  when  the  hand  is  placed  over  the  tumor, 
and  frequently  a  tremor  or  thrill  resembling  that  communicated 
by  an  aneurismal  varix.  Dr.  Stokes  cites  an  instance  in  which  it 
was  mistaken  for  aneurism.  An  arterial  bellows  murmur  is  pro- 
duced within  the  tumor,  and,  in  some  instances,  also  a  continuous 
venous  hum.  The  latter  is  sometimes  musical,  and  has  been 
known  to  be  suflSciently  loud  to  attract  the  attention  of  the  patient. 
Unusual  pulsation  of  the  arteries  of  the  neck  coexists  with  arterial 
murmur.  The  inferior  thyroid  arteries  have  been  found  to  become 
much  enlarged.  The  cervical  veins  are  notably  dilated,  and  yield 
a  continuous  murmur  or  hum. 

These  phenomena  pertaining  to  the  thyroid  body  in  the  great 
majority  of  cases  have  been  observed  in  females.  They  have  not 
been  observed  to  occur  before  puberty.  Hysterical  symptoms  have 
been  present  in  some  instances.  Neuralgia  is  an  occasional  con- 
comitant. Ancemia  coexists  generally.  As  regards  the  heart,  the 
cases  have  been  characterized  by  long-continued,  excessive  action 
of  the  organ,  or  frequently  recurring  palpitation.  The  physical 
evidence  of  organic  disease  has  in  some  instances  been  present  and 
sometimes  wanting.  The  amount  of  information  obtained  by  exa- 
minations after  death  is,  as  yet,  meagre.  In  a  fatal  case  reported 
by  Dr.  Marsh  with  the  autopsical  appearances,  the  heart  was  en- 
larged, especially  the  auricles,  and  the  auriculo-ventricular  valves 
on  both  sides,  more  especially  on  the  right  side,  were  thickened  by 
morbid  deposit.  In  another  instance,  communicated  to  Dr.  Stokes 
by  Professor  Smith,  of  Dublin,  slight  aortic  lesions  existed,  and  the 
left  ventricle  was  largely  hypertrophied  and  dilated.  In  a  third 
case,  detailed  by  Dr.  Begbie,  the  heart  was  large,  soft,  and  flaccid ; 
all  the  cavities,  but  especially  the  ventricles,  were  dilated,  and  the 
valves  were  sound. 

My  own  experience  furnishes  but  little  with  regard  to  this  sub- 
ject.    It  is  not  improbable  that  examples  may  have  fallen  under 


EXLARGEMEXT    OF    THYROID    BODY.  269 

ray  observation  without  having  been  noted,  inasmuch  as  my  atten- 
tion has  been  directed  to  the  subject  only  for  the  last  four  or  five 
years.  Within  this  period  I  have  met  with  three  instances  of  an 
enlarged  and  pulsating  thyroid  body  in  connection  with  a  notable 
degree  of  cardiac  disorder.  In  all  these  instances  the  patients  were 
females.  In  one  the  patient  was  twenty-seven  years  of  age,  had 
been  married  eleven  years,  and  had  had  five  children,  four  of  which 
she  had  nursed  for  twelve  months.  At  the  time  of  my  examination 
she  was  five  months  advanced  in  pregnancy,  and  her  youngest  child 
was  two  years  of  age.  The  enlargement  of  the  thyroid  body  com- 
menced shortly  after  the  last  confinement.  It  was  considerably 
enlarged,  and  pulsated  strongly.  It  is  not  noted  whether  murmurs 
and  fremitus  existed  in  the  tumor.  She  had  suffered  from  inordi- 
nate action  of  the  heart  for  a  year  and  a  half.  The  action  of  the 
heart  was  not  irregular,  and  the  pulse  numbered  one  hundred  and 
twelve.  Her  appearance  was  not  in  a  marked  degree  anasmic.  She 
was  affected  with  intercostal  neuralgia.  The  impulse  of  the  heart 
was  abrupt  and  smart,  with  violent  shock,  but  no  heaving.  No 
endocardial  murmur  was  discovered.  The  sounds  were  normal. 
Owing  to  the  large  development  of  the  mammae,  it  was  not  easy  to 
determine  the  size  of  the  heart.  The  patient  was  from  a  distance, 
and  the  subsequent  history  of  the  case  is  unknown.  In  the  second 
case  the  age  of  the  patient  was  fifty-seven.  She  was  the  wife  of  a 
farmer,  and  had  been  accustomed  to  hard  work  in  the  management 
of  a  dairy.  Menstruation  had  ceased  three  years  before.  Thirteen 
years  prior  to  my  examination  she  had  acute  articular  rheumatism. 
For  more  than  a  year  she  had  been  troubled  with  palpitation, 
occurring  especially  at  night,  and  produced  by  any  excitement.  It 
was  unattended  by  dj^spnoea.  Considerable  enlargement  of  the 
thjn'oid  body  had  existed  for  about  a  year.  On  my  first  examina- 
tion no  murmur  was  discovered.  The  situation  of  the  apex-beat 
was  normal;  the  force  of  the  impulse  was  not  increased,  and  no 
abnormal  modifications  of  the  heart-sounds  were  observed.  A  year 
afterward  a  soft  systolic  bellows  murmur  over  the  apex  was  dis- 
covered, without  any  other  signs  of  organic  disease.  The  palpi- 
tations still  continued.  The  subsequent  history  is  not  known.  The 
third  case  came  under  observation  quite  recently.  The  patient  is  a 
young  girl  aged  nineteen,  presenting  a  healthy  aspect,  the  counte- 
nance not  denoting  anaemia.  She  had  been  conscious  of  increased 
action  of  the  heart  for  a  year.  The  pulse  was  one  hundred  and 
twenty,  and  had  been  even  more  frequent.     The  enlargement  was 


270      AFFECTIONS   INCIDENTAL    TO    ORGANIC    DISEASES. 

moderate,  the  body  on  the  right  side  being  more  affected  than  that 
on  the  left.  There  existed  strong  pulsation  and  a  bellows  murmur 
on  both  sides  over  the  tumors;  also  arterial  bellows  murmur  and 
venous  hum  over  the  carotids  and  jugular  veins.  The  heart-sounds 
in  this  case  were  intensified,  but  otherwise  not  abnormal.  No  endo- 
cardial murmur  was  discovered,  and  the  heart  did  not  appear  to  be 
enlarged.     Prominence  of  the  eyeball  existed  in  this  case. 

The  view  taken  by  Drs.  Graves  and  Stokes  of  the  pathological 
connection  supposed  to  exist  between  enlargement  of  the  thyroid 
body  and  an  abnormal  condition  of  the  heart  is,  that  the  former 
may  occur  in  consequence  of  undue  rapidity,  irregularity,  and  force 
of  cardiac  action,  persisting  for  a  sufficiently  long  period.  Agree- 
ably to  this  view,  the  heart  may  or  may  not  be  affected  with  organic 
disease.  Prolonged  functional  excitement  appears  to  be  regarded 
as  the  essential  abnormal  condition,  and  this  condition  may  be 
associated  with  different  lesions,  or  the  organ  may  be  structurally 
sound.  In  the  majority  of  the  cases  which  have  been  reported, 
physical  signs  have  been  present  denoting  either  enlargement  or 
some  organic  change.  It  is  evident  that  the  subject  claims  farther 
clinical  study,  and  that  the  data  are  at  present  insufficient  to  war- 
rant positive  conclusions  respecting  the  nature  and  extent  of  the 
relations  existing  between  the  phenomena  pertaining  to  the  thyroid 
body  and  those  referable  to  the  heart. 

Prominence  of  the  eyes  has  been  observed  as  a  concomitant  of 
the  affection  of  the  thyroid  body.  It  was  noted  by  Dr.  Parry  in 
one  of  the  seven  cases  which  he  recorded  of  the  latter  affection. 
It  coexisted  and  was  more  or  less  marked  in  the  cases  reported  by 
the  other  observers  whose  names  have  been  mentioned.  The  ap- 
pearance of  the  eyes  is  peculiar  and  striking.  The  protuberance  of 
the  globes  renders  visible  a  broader  portion  of  the  tunica  albuginea 
surrounding  the  cornea  than  usual,  and  gives  to  the  countenance  a 
wild,  staring  expression,  which,  as  Dr.  Taylor  remarks,  when  once 
seen,  will  never  be  forgotten.  The  conjunctiva  and  other  coats 
may  remain  clear  and  transparent,  and  sometimes  the  eyes  acquire 
an  unusual  brilliancy.  The  pupil  is  not  affected.  Vision  is  unim- 
paired. The  condition  is  unattended  by  pain.  In  some  instances 
the  projection  of  the  eyeballs  is  so  great  that  the  lids  are  unable  to 
cover  them,  and  the  patient  sleeps  with  the  eyes  partially  open ; 
yet  Dr.  Stokes  states  that  under  these  circumstances  the  sense  of 
sight  did  not  sufi'er,  and  ophthalmia  was  not  developed  in  a  case 
which  remained  under  his  observation  for  more  than  a  year.     The 


ENLARGEMENT    OF    THYROID    BODY.  271 

affection  is  sometimes  developed  suddenly.  In  a  case  referred  to  by 
Dr.  Stokes  it  became  apparent  after  a  long-continued  fit  of  coughing 
and  retching.  An  instance  in  which  it  occurred  during  a  single 
night  is  related  by  Kobert  Taj^lor. 

The  rationale  of  this  remarkable  appearance  of  the  eyes  is  not 
fully  understood.  Dr.  Stokes  attributes  it  to  enlargement  of  the 
eyeballs  from  an  increase  in  the  vitreous  and  aqueous  humors,  and 
considers  it  therefore  as  denoting  a  form  of  hydrophthalmia,  or 
general  dropsy  of  the  eye.  This  explanation  is  hardly  consistent 
with  the  absence  of  pain,  of  defect  of  vision,  etc.  It  is,  moreover, 
disproved  by  a  fact  stated  by  Eobert  Taylor,  viz.,  the  balls  can  be 
readily  replaced  by  gentle  pressure.  The  hypothesis  of  Mr.  Dal- 
rymple  is  more  plausible.  He  attributes  it  to  "an  absence  of  the 
proper  tonicity  of  the  muscles  by  which  the  eyes  are  retained  in 
their  natural  positions  in  the  orbit,  and  some  amount  of  venous 
congestion  of  the  tissues  forming  the  cushion  behind  the  globes."* 
From  the  cases  which  have  been  reported  it  would  appear  that  it  is 
almost  invariably  associated  with  enlargement  of  the  thyroid  body, 
and  that  the  latter  first  occurs.  Hence  there  is  room  for  the  con- 
jecture that  it  is  incidental  to  enlargement  of  the  thyroid  body,  and 
if  dependent  on  an  abnormal  condition  of  the  heart,  it  is  so  indi- 
rectly. Another  conjecture  is,  that  enlargement  of  the  thyroid 
body  and  prominence  of  the  eyes  are  different  effects  of  a  common 
pathological  condition,  whatever  it  may  be,  the  latter  effect  being 
less  frequent,  and  rarely  occurring  without  the  former. 

With  regard  to  this  subject,  I  can  contribute  from  my  own 
experience  even  less  than  with  regard  to  the  subject  just  considered. 
I  have  met  with  a  single  example  only,  and,  by  a  curious  coinci- 
dence, it  has  occurred  since  I  commenced  this  chapter.  The  case 
has  been  already  referred  to,  being  the  third  of  the  three  cases  of 
which  an  account  was  given  in  connection  with  the  subject  of 
enlargement  of  the  thyroid  body.  Abnormal  rapidity  of  the  heart's 
action  preceded  the  prominence  of  the  eyes  for  seven  or  eight 
months.  The  projection  was  noticed  all  at  once,  and  the  patient 
states  that  it  followed  violent  fits  of  coughing.  Both  eyes  were 
affected,  but  the  right  much  more  than  the  left.  The  thyroid  body 
was  also  more  enlarged  on  the  right  side  than  on  the  left.  The 
general  health  of  the  patient  has  been,  and  is  now  apparently  good. 
She  is  19  years  of  age,  and  presents  a  healthy  aspect.  The  coun- 
tenance does  not  denote  anaemia,  but  a  loud  venous  hum,  as  well 

'  Quoted  from  article  by  Dr.  Taylor. 


272      AFFECTIONS    INCIDENTAL    TO    ORGANIC    DISEASES. 

as  arterial  murmur,  exists  in  the  neck.  She  had  had  for  several 
weeks  a  dry  irritable  cough,  without  any  other  evidence  of  pul- 
monary disorder.  The  heart  did  not  appear  to  be  enlarged  ;  the 
sounds  were  normal,  except  that  they  were  intensified,  and  no 
endocardial  murmur  was  discoverable.  The  pulse  had  ranged 
from  120  to  130.  At  the  time  of  my  examination,  it  was  120.  At 
that  time,  the  left  eye  projected  but  slightly,  and  the  projection 
of  the  right  eye  had  diminished.  Vision  was  unaffected;  the  pupils 
were  natural;  pressure  gave  no  pain,  and  there  was  no  injection  of 
the  vessels.  An  instance  was  once  related  to  me  by  a  non-medical 
friend,  which  is  worthy  of  being  referred  to,  from  the  fact  that  the 
prominence  of  the  eyes  was  attributed  by  the  patient  and  her  family 
to  the  injudicious  use  of  iodine  to  resolve  enlargement  of  the  thy- 
roid body.  The  medical  attendant  was  held  responsible  for  the 
occurrence,  and  I  suspect  was  not  prepared  to  vindicate  himself 
by  asserting  the  existence  of  a  pathological  connection  between  the 
two  affections.  The  patient,  as  I  have  learned,  had  suffered  much 
and  long  from  disturbed  action  of  the  heart  prior  to  the  develop- 
ment of  these  affections.  In  the  case  which  has  recently  come 
under  my  observation,  a  tonic  course  of  treatment  has  been  pursued 
and  is  still  continued,  consisting  of  preparations  of  iron,  generous 
diet,  and  exercise  in  the  open  air. 

It  is  evident  that  further  investigation  is  needed  to  elucidate  the 
pathological  character  and  relations  of  this,  as  well  as  the  associated 
affection  previously  considered.  With  our  present  knowledge,  the 
agency  of  an  abnormal  condition  of  the  heart  in  its  production, 
directly  or  indirectly,  cannot  perhaps  be  considered  as  conclusively 
determined;  and  if  it  be  referable  to  the  heart's  action,  the  nature 
and  extent  of  its  connection  with  the  latter,  remain  to  be  ascertained. 
These  points  are  of  interest  and  importance,  but  their  discussion 
here  would  be  out  of  place.  It  is  proper,  however,  to  add  that  some 
writers  attribute  both  affections  to  the  co-existing  anaemia  which 
exists  in  a  marked  degree,  in  the  majority  of  cases.  This  view  is 
taken  by  Dr.  Begbie,*  and  also  by  Dr.  Taylor,  of  New  York,  and 
by  Eobert  Taylor,  of  London,  in  the  articles  already  referred  to. 

It  is  important,  of  course,  to  discriminate  between  prominence  of 
the  eyes,  supposed  to  be  incidental  to  an  affection  of  the  heart,  and 
the  enlargement  or  protrusion  due  to  certain  diseases  of  the  eye- 

'  "  Ansemia  and  its  Consequences  ;  Enlargement  of  the  Thyroid  Gland  and  Eye- 
balls ;  Aniemia  and  Goitre,  are  they  related  ?"  Edinburgh  Montidy  Journal,  vol.  ix. 
Feb'y  1849. 


PROMINENCE    OF    THE    EYES.  273 

ball,  tumor  within  the  orbit,  cerebral  disease,  etc.  This  is  not 
difficult.  The  fact  that  both  eyes  are  simultaneously  affected  ;  the 
coexistence  of  enlargement  of  the  thyroid  body,  of  disordered 
action  of  the  heart,  and,  generally  at  least,  of  anaemia ;  the  absence 
of  pain,  of  local  inflammation,  of  defective  vision,  and  of  symptoms 
pointing  to  the  brain  as  the  seat  of  disease,  render  the  diagnosis 
sufficiently  easy. 

The  prognosis  in  cases  in  which  enlargement  of  the  th3n'oid 
body  and  prominence  of  the  eyes  occur,  exclusive  of  the  cardiac 
lesions  with  which  they  may  be  associated,  is  not  unfavorable. 
Danger  to  life  is  not  involved  in  the  occurrence  of  one  or  both  of 
these  events.  Their  liability  to  continue  indefinitely,  the  incon- 
venience attending  them,  and  the  deformity  which  they  occasion, 
are,  however,  not  inconsiderable  evils.  The  final  result  will  depend 
on  the  coexisting  morbid  conditions.  It  would  be  injudicious  to 
encourage  confident  expectations  of  complete  recovery  ;  but  marked 
improvement,  if  not  cure,  may  in  many,  if  not  most  instances,  be 
expected.  The  projection  of  the  eyeballs  often  disappears,  or 
diminishes  so  as  to  leave  only  a  slightly  unnatural  expression. 
The  thyroid  body  becomes,  after  a  time,  in  favorable  cases,  solid 
and  more  or  less  lessened  in  size,  the  pulsation,  thrill  and  murmurs 
gradually  disappearing.  These  changes  take  place  very  slowh'. 
The  statements  just  made  embody  the  conclusions  drawn  by  Dr. 
Stokes  from  his  own  experience  and  that  of  others ;  but  the  accumu- 
lation of  a  larger  number  of  cases  is  desirable  to  serve  as  the  basis 
of  our  knowledge  of  the  natural  tendencies  of  the  affections,  and  the 
extent  to  which  they  are  amenable  to  treatment. 

The  indications  for  treatment  relate  mainly  to  the  associated 
pathological  conditions.  Inordinate  activity  of  the  heart  as  regards 
rapidity  or  force,  and  irregularity  of  action,  claim  those  measures 
which  are  suited  to  allay  the  morbid  irritability  of  this  organ.  The 
consideration  of  this  object  of  treatment  belongs  properly  to  the 
subject  of  functional  disorders  of  the  heart,  to  which  a  distinct 
chapter  will  be  devoted.  Coexisting  anemia  calls  for  the  treat- 
ment suited  to  that  condition.  Disorder  of  the  catamenia  (which 
is  common),  and,  in  fact,  of  any  of  the  functions  of  the  body,  is  to 
be  remedied  if  practicable.  It  is  yet  to  be  ascertained  whether  any 
special  treatment,  aside  from  these  indications,  may  be  employed 
with  advantage.  Organic  affections  of  the  heart,  if  present,  demand 
the  treatment  already  considered. 
18 


274      AFFECTIONS   INCIDENTAL    TO    ORGANIC    DISEASES. 


REDUPLICATION   OF   THE   HEART-SOUNDS. 


Reduplication,  or  doubling  of  one  or  both  of  the  sounds  of  the 
heart,  is  a  rare  auscultatory  sign  which  was  not  considered  in 
treating  of  organic  affections,  because  it  has  not  been  found  to  be 
incidental  to  any  particular  form  of  cardiac  lesion.  Although,  as 
a  physical  sign,  it  has  not  much  practical  value,  it  claims  attention 
as  denoting  a  curious  and  interesting  aberration  of  the  heart's 
action,  and  it  is  important  for  the  practitioner  to  be  prepared  to 
recognize  it.  in  order  that  he  may  appreciate  what  would  otherwise 
be  an  unintelligible  anomaly.  Either  of  the  sounds  may  be 
doubled  singly,  or  the  two  sounds  may  be  reduplicated.  Redupli- 
cation of  the  second  or  diastolic  sound  is  the  variety  oftenest 
observed.  This  is  not  extremely  uncommon.  Instances  in  which 
the  first  sound  is  doubled  are  much  more  infrequent;  and  examples 
of  the  reduplication  of  both  sounds  are  so  rare  that  they  are  justly 
included  among  the  curiosities  of  clinical  experience.  Using  for 
the  present  purpose  the  expression  tic-tac  as  the  symbol  represent- 
ing the  normal  sounds,  the  three  varieties  of  reduplication  may  be 
verbally  expressed  thus:  Doubling  of  the  first  or  systolic  sound  by 
tic  tic-tac  ;  of  the  second,  or  diastolic  sound  by  tic-tac  tac ;  of  both 
sounds  by  tic  tic-tac  tac.  In  the  two  first  varieties,  or  when  one 
only  of  the  sounds  is  doubled,  three  sounds  occur  during  a  single 
beat  or  revolution  of  the  heart;  in  the  last  variety,  or  when  both 
sounds  are  reduplicated,  four  sounds  are  heard  with  each  revolu- 
tion or  beat.  Bouillaud  compares  the  rhythmical  succession  of  the 
triple  sounds,  when  the  second  sound  is  doubled,  to  the  dactyle  in 
poetical  metre,  and  the  rebound  of  a  hammer  on  an  anvil ;  and 
when  the  first  sound  is  doubled,  to  the  tattoo  (rappel)  of  the  drum, 
or  the  sounds  of  the  feet  of  a  galloping  horse. 

Bouillaud  claims  to  have  been  the  first  to  describe  reduplicated 
heart-sounds.  He  states  that,  in  the  first  edition  of  his  treatise  on 
Diseases  of  the  Hearty  published  in  183-i,  he  was  able  to  cite  but  a 
single  instance ;  but,  before  the  appearance  of  the  second  edition  in 
1841,  he  had  collected  several  examples,  so  that  the  phenomena 
could  no  longer  be  discredited,  as  they  had  been  by  some.'     The 

'  Lemons  Cliniques  sur  les  Maladies  du  CcDur,  etc.,  par  M.  Bouillaad,  recueillies 
et  redig6es  par  le  Dr.  V.  Racle,  Paris,  1853. 


REDUPLICATION    OF    HEART-SOUNDS.  275 

reality  of  the  sign  has  been  abundantly  confirmed  by  other  ob- 
servers. 

Of  twelve  cases  of  different  varieties  of  reduplication,  the  his- 
tories of  which  are  given  in  the  second  edition  of  the  treatise  by 
Bouillaud,  in  one  only  were  both  sounds  doubled.  In  that  instance 
the  sounds  were  at  first  tripled,  and  afterwards  became  quadrupled. 
The  four  sounds  for  each  beat  were  very  distinct,  and  the  correct- 
ness of  the  observation  was  verified  by  several  observers  sufficiently 
skilled  in  physical  exploration.  In  this  instance  double  pulsation 
of  the  arteries  was  also  observed.  The  details  of  two  cases  are 
given  by  another  French  author,  Dr.  Charcelay,  of  Tours ;^  one  of 
these  cases  came  under  his  own  observation,  and  the  other  is 
quoted  from  a  thesis  by  M.  Pressat,  published  in  1837.  Eeference 
will  be  made  to  these  cases  presently.  An  example  as  striking  as 
any  on  record  was  reported  by  me  in  1855.^  The  case  came  under 
my  observation  at  the  Louisville  Marine  Hospital  in  1853.  The 
patient  was  a  sailor,  aged  twenty-seven,  and  was  admitted  for  a 
cough  which  he  attributed  to  taking  cold  six  weeks  before.  On 
comparing  the  pulsations  of  the  radial  artery  with  the  heart-sounds, 
there  existed  four  sounds  for  each  pulse.  The  number  of  double 
sounds  was  precisely  twice  as  many  as  the  number  of  radial  pulsa- 
tions per  minute.  This  exact  ratio  was  invariably  preserved  when- 
ever the  comparison  was  made  for  at  least  seventeen  days.  During 
this  period,  the  comparison  was  made  by  several  persons  besides 
myself.  The  carotid  pulse,  however,  occurred  in  the  ratio  of  one 
to  every  two  sounds  of  the  heart ;  in  other  words,  it  was  precisely 
twice  as  frequent  as  the  radial  pulse.  The  heart  was  evidently 
enlarged,  and  a  feeble,  short  murmur  was  heard  at  the  apex.  The 
apex-beat  was  not  distinctly  appreciable  either  to  the  eye  or  touch. 
The  patient  was  walking  about,  and  was  able  to  take  active  mus- 
cular exercise.  Subsequently,  the  face  and  lower  limbs  became 
somewhat  cederaatous,  and  he  suffered  from  dyspnoea.  These 
symptoms  disappeared,  and  he  was  discharged  quite  well,  after 
being  two  months  in  hospital.  When  discharged,  the  pulse  and 
two  sounds  of  the  heart  were  in  normal  ratio,  being  eighty-four 
per   minute,  and    the   bellows   murmur   had   disappeared.      The 

'  Memoire  sur  plusieurs  Cas  remarkables  de  defaut  de  SjBchronisme  des  Batte- 
ments  et  des  Bruits  des  Ventricules  du  Coeur.  Archives  Generales  de  Medecine, 
1838. 

^  Buffalo  Medical  Journal,  vol.  ii.,  No.  1,  Maj,  1855.  Also  Western  Medical 
Journal,  1855. 


276      AFFECTIONS    IXCIDEXTAL    TO    ORGANIC    DISEASES. 

patient  remained  apparently  healthy,  performing  active  labor  for 
five  years  afterwards.  lie  then  died  with  some  affection  foreign  to 
the  heart,  and  a  post-mortem  examination  with  reference  to  the 
latter  was  made  by  my  friend.  Prof.  T.  G.  Eichardson,  now  of  the 
University  of  Louisiana.  The  heart  was  moderately  enlarged, 
without  any  appearances  denoting  valvular  disease. 

Eeduplication  of  one  of  the  heart-sounds,  as  already  stated,  is 
not  extremely  uncommon.  In  most  cases  it  is  the  second  or  dias- 
tolic sound  which  is  doubled.  I  have  met  with  a  few  examples  of 
this  variety.  It  must  be  comparatively  rare  to  meet  with  cases  in 
which  the  first  sound  is  alone  doubled.  None  have,  as  yet,  fallen 
under  my  observation. 

Eeduplications  may  be  perceived  only  when  the  stethoscope  is 
placed  at  certain  points  within  the  pr^cordia.  If  the  instrument 
be  moved  to  other  points,  the  sounds,  as  regards  number,  are  nor- 
mal. Dr.  "Walshe  gives  the  results  of  his  observations  with  respect 
to  the  particular  situations  in  which,  in  different  cases,  he  has  found 
the  first  and  second  sound,  respectively,  doubled,  as  follows :  The 
first  or  systolic  sound  may  be  double  at  the  apex  over  the  left  ven- 
tricle, single  over  the  right  ventricle,  and  either  single  or  double  at 
the  base ;  it  may  be  double  over  the  right  ventricle,  and  single 
over  the  left  ventricle  at  the  apex  and  at  the  base ;  it  may  be  double 
at  the  base,  single  at  the  apex  over  the  left  ventricle,  and  imper- 
fectly reduplicated  over  the  right  ventricle.  The  second,  or  dias- 
tolic sound  may  be  double  at  the  base  and  single  at  the  apex  ;  or 
it  may  be  double  over  the  right  ventricle  and  single  over  the  left 
ventricle  at  the  apex  and  at  the  base.  In  the  cases  in  which  I  have 
observed  reduplication  of  the  second  sound,  it  has  been  noted  as 
occurring  at  the  base.  In  the  instance  in  which  both  sounds  were 
reduplicated,  they  were  all  distinctly  heard  by  auscultating  over 
the  body  of  the  heart.  In  the  case  reported  by  M,  Pressat,  the  four 
sounds  were  heard  within  a  space  quite  limited,  corresponding  to 
the  interventricular  and  interauricular  septa.  In  this  situation,  the 
sounds  succeeded  each  other  rapidly,  without  interruption,  resem- 
bling, as  the  author  states,  the  blows  of  a  hatteur  depldtre. 

The  cardiac  lesions  found  after  death  in  cases  in  which  redupli- 
cations have  been  observed,  are  not  uniform.  In  all  of  five  cases 
reported  by  Bouillaud,  valvular  lesions  existed,  involving  contrac- 
tion at  the  aortic  orifice  in  three,  and  at  the  mitral  orifice  in  two 
cases.  The  heart  was  enlarged  in  all  these  cases.  Tricuspid  in- 
sufficiency, with  hypertrophy,  was  found  in  the  case  of  quadrupled 


REDUPLICATION"    OF    HEART-SOUNDS.  277 

sounds  reported  by  Dr.  Charcelay,  the  other  valves  being  sound. 
In  two  cases  observed  by  Dr.  Bellingham,  in  which  the  first  or 
systolic  sound  was  doubled,  the  right  ventricle  was  much  dilated 
and  hypertrophied,  and  the  valves  at  the  left  side  of  the  heart  were 
sound.  The  condition  of  the  tricuspid  and  pulmonic  valves  is  not 
mentioned.  In  the  case  reported  by  me  of  reduplication  of  both 
sounds,  as  already  stated,  the  heart  five  years  afterwards,  -when 
death  occurred,  was  found  to  be  enlarged  without  valvular  disease. 
In  another  case  under  my  observation  in  which  reduplication  of 
the  second  sound  was  ascertained  a  few  days  before  death,  the 
patient  died  of  pericarditis  and  pleuritis  developed  in  connection 
with  Bright's  disease.  The  heart,  on  examination  after  death,  was 
greatly  enlarged,  but  the  valves  were  sound.  Bouillaud  was  led 
by  the  post-mortem  appearances  in  the  cases  which  he  had  observed, 
to  conclude  that  reduplication  does  not  occur,  except  in  connection 
with  organic  disease  involving  valvular  lesions  with  either  con- 
striction or  insufficiency.  The  facts  just  stated  suffice  to  disprove 
this  conclusion.  Valvular  lesions  were  wanting  in  the  case  observed 
by  me  in  which  both  sounds  were  doubled.  The  absence  of  val- 
vular lesions,  moreover,  is  evidenced  by  the  physical  signs  denot- 
ing their  presence  being  deficient  in  a  certain  proportion  of  cases. 
Valvular  lesions  may  or  may  not  be  present ;  they  are  not  essential 
to  the  presence  of  this  sign.  In  all  the  reported  fatal  cases  which 
have  fallen  under  my  notice,  however,  as  well  as  in  the  few  cases 
that  have  come  under  my  observation,  the  heart  was  more  or  less 
enlarged.  It  is  probable  that  reduplication  never  occurs  except  in 
cases  of  enlargement  of  the  heart. 

The  mechanism  of  reduplication  of  the  heart-sounds  is  an  inter- 
esting point  of  inquiry.  The  explanation  at  first  offered  by  Bouil- 
laud was,  that  the  systolic  and  diastolic  movements  of  the  ventricles 
take  place  synchronously,  but  consist  each  of  two  distinct  efforts 
(reprises)',  that  is  to  say,  each  systole  and  diastole  is  divided  into 
two  acts,  and  each  act  attended  by  a  sound.  The  disorders  of 
rhythm,  according  to  this  hypothesis,  is  analogous  to  interrupted 
or  jerking  respiration,  called  by  the  French  writers,  entrecoupee. 
It  is  assumed  in  this  explanation,  that  the  diastolic  sound  of  the 
heart  is  due  to  an  active  dilatation  of  the  ventricles,  and  not  to  the 
recoil  of  the  aorta  and  pulmonic  artery,  the  latter,  probably,  being 
in  fact  the  immediate  cause  of  the  expansion  of  the  semilunar 
valves  which  occasions  this  sound.  In  his  Lecons  Cliniques,  pub- 
lished in  1853,  however,  Bouillaud   adopts  the  explanation  now 


278      AFFECTIONS   INCIDENTAL    TO    ORGANIC    DISEASES. 

generally  received,  as  more  satisfactory  than  that  previously  oSered 
by  himself.  Agreeably  to  this  explanation,  the  reduplication  is 
caused  by  the  failure  of  the  two  ventricles  to  contract  in  unison. 
This  is  the  hypothesis  advocated  by  Dr.  Charcelay  in  the  article 
already  referred  to.  It  has  been  adopted  by  late  writers  on  diseases 
of  the  heart,  so  far  as  I  know,  without  an  exception.  Dr.  Charcelay, 
in  the  case  of  quadrupled  sounds  reported  by  him,  regarded  as  proof 
of  the  non-synchronism  of  the  ventricular  contractions,  the  occur- 
rence of  jugular  pulsations  which  were  not  synchronous  with  the 
pulsations  of  the  carotids.  Tricuspid  insufficiency  in  that  case  was 
shown  to  exist  by  the  examination  after  death,  and  it  is  highly  pro- 
bable that  the  alternate  pulsations  of  the  vein  and  the  artery  were 
due  to  the  contractions  of  the  two  ventricles  not  being  in  unison. 
The  proof,  however,  is  not  complete,  since  the  jugular  pulsations, 
which  were  not  synchronous  with  those  of  the  artery,  may  have 
been  produced  by  contractions  of  the  right  auricle.  In  the  ex- 
ample reported  by  me  of  reduplication  of  both  sounds,  the  pulsa- 
tions of  the  carotid  artery  occurred  in  the  ratio  of  one  to  two  of  the 
heart-sounds,  being  precisely  double  the  pulsations  of  the  radial 
artery.  Bouillaud  also  states  that,  in  the  example  observed  by 
him,  there  was  reduplication  of  the  arterial  pulse.  How  is  this  to 
be  reconciled  with  the  hypothesis  of  non-synchronism  of  the  con- 
tractions of  the  two  ventricles  ?  Unless  accounted  for,  it  certainly 
is  inconsistent  with  that  hypothesis.  It  may  be  accounted  for  on 
the  supposition  of  a  bis  feriens  or  dicrotic  pulse  :  that  is,  after  an 
arterial  diastole  produced  by  the  contraction  of  the  left  ventricle, 
the  recoil  of  the  aorta  was  sufficient  to  give  rise  to  a  second  arterial 
diastole  in  the  carotid,  sufficiently  strong  to  be  perceptible  here, 
but,  in  my  case,  not  in  the  arteries  more  remote  from  the  heart.^ 
On  the  whole,  with  our  present  knowledge,  the  phenomena  of  re- 
duplication are  explained  most  satisfactorily,  by  supposing  that  the 
two  ventricles  fail  to  contract  in  unison.  According  to  this  ra- 
tionale, the  tricuspid  and  mitral  valves  are  made  tense,  not  simul- 
taneously, but  successively,  in  consequence  of  the  contraction  of 
one  ventricle  being  completed  before  that  of  the  other;  and  the 
semilunar  valves  of  the  aorta  and  pulmonic  artery  expand  alter- 
nately, instead  of  coiucidently,  since,  in  consequence  of  the  differ- 
ence in  time  between  the  completion  of  the  contractions  of  the 

'  A  dicrotic  pulsation  of  the  cai-otids,  when  the  movements  of  this  artery  are 
visible,  is  sometimes  distinctly  apjiarent  to  the  eye. 


REDUPLICATION    OF    HEART-SOUNDS.  279 

right  and  left  ventricle,  the  recoil  of  the  coats  of  each  of  these  two 
vessels  does  not  occur  at  the  same  instant.  Hence,  the  conditions 
for  the  doubling  of  both  sounds  always  exist,  although  one  sound 
only,  either  the  first  or  second,  may  be  reduplicated  ;  but  it  is 
readily  conceivable  that  one  only  may  be  reduplicated  with  inten- 
sity sufficient  to  be  appreciable  by  auscultation.  It  is  also  intelli- 
gible that  the  reduplication  is  often  perceived  only  within  a  limited 
portion  of  the  praecordia. 

Dr.  Walshe  remarks,  that  "the  real  interest  of  reduplications 
arises  out  of  their  bearing  on  the  theory  of  the  heart-sounds."  He 
asks,  "How  is  the  fact  that  the  second  sound  may  be  continuously 
doubled  at  the  base,  and  perfectly  pure  and  single  at  the  apex,  ex- 
plicable on  the  simple  sigmoid  theory  of  the  second  sound  ?"  He 
adds,  "A  double  sound  does  not  become  single  by  conduction  over  so 
short  a  space."  This  fact  seems  to  me  to  be  susceptible  of  an  easy 
explanation,  without  conflicting  with  the  theory' which  refers  the 
production  of  the  second  sound  to  the  semilunar  valves.  Exami- 
nations of  the  healthy  chest  show  that  the  pulmonic  second  sound 
is  weak,  as  compared  with  the  aortic  second  sound.  The  former  is 
only  distinguishable,  as  a  rule,  in  the  first,  second,  or  third  inter- 
costal spaces  on  the  left  of  the  sternum.  The  second  sound  heard 
over  the  apex,  and  elsewhere  more  or  less  removed  from  the  points 
just  named,  emanates  from  the  aorta.  Hence,  when  the  second 
sound  is  reduplicated  at  the  base  of  the  heart,  the  reduplication 
may  not  extend  to  the  apex,  simply  because  the  pulmonic  sound  is 
not  propagated  so  far.  Owing  to  the  relative  weakness  of  the  pul- 
monic second  sound,  the  reduplication  may  be  appreciable  at  the 
base  of  the  heart  on  the  left,  and  not  on  the  right  side  of  the  ster- 
num. Again,  the  fact  that  "  the  first  sound  may  be  single  at  the 
left  apex  and  at  the  base,  while  it  is  distinctly  reduplicate  at  the 
right  apex,"  appears  to  Dr.  Walshe  to  denote  that  the  first  sound 
consists  of  a  ventricular  and  an  arterial  portion,  and  that  the  two 
are  separated  on  the  right  side  of  the  heart.  But  this  fact  seems 
to  be  explicable  readily  by  the  weakness  of  the  tricuspid  valvular 
element  of  the  first  sound,  as  compared  with  the  mitral  valvular 
element.  The  tricuspid  valvular  element  is  appreciable  only  over 
the  right  ventricle;  hence  a  doubled  first  sound  may  be  heard 
in  that  situation  only,  simply  because  the  tricuspid  sound  is  not 
strong  enough  to  be  transmitted  to  the  left  apex  and  to  the  base. 
Finally,  Dr.  Walshe  cites  the  fact  that  the  second  sound  may  be 
single  at  the  base  and  double  at  the  left  apex,  as  tending  to  show 


280      AFFECTIONS    INCIDENTAL    TO    OEGANIC    DISEASES. 

strongly  the  partial  origin  of  the  second  sound  within  the  ventricle. 
This  fact  is  not  so  readily  explained,  and  I  cannot  but  think  that 
whenever  the  second  sound  is  doubled  at  the  left  apex,  it  will  be 
found  to  be  reduplicated  over  the  pulmonic,  although  it  may  be 
single  over  the  aortic  artery.  The  pulmonic  sound  may,  in  some 
instances,  be  propagated  as  far  as  the  apex  of  the  heart,  especially 
when  the  right  ventricle  is  hypertrophied,  while  it  is  not  apprecia- 
ble over  the  aorta.' 

Reduplicated  heart-sounds  are  distinguished,  in  general,  without 
difficulty,  if  the  auscultator  be  prepared  to  recognize  them  by  a 
proper  knowledge  of  the  subject.  The  occurrence  of  three  sounds 
with  a  single  beat  is  easily  determined,  and  the  rhythm  shows,  at 
once,  whether  it  be  the  first  or  the  second  sound  which  is  doubled. 
The  latter,  it  is  to  be  borne  in  mind,  is  reduplicated  much  oftener 
than  the  former,  and  this  variety  of  reduplication,  certainly  as  a 
rule,  will  be  most  marked,  and  perhaps  perceived  exclusively  at 
the  base  of  the  heart.  As  just  stated,  it  will  be  most  likely  to  be 
discovered  over  the  pulmonic  artery,  i.  e.,  in  the  second  intercostal 
space  on  the  left  side  of  the  sternum.  Reduplication  of  the  first 
sound  is,  I  suspect,  most  likely  to  be  observed  over  the  right  ven- 
tricle. The  movements  of  the  apex  of  the  heart  against  the  walls 
of  the  chest,  in  some  cases,  give  rise  to  a  prolonged  and  interrupted 
sound  (element  of  impulsion)  which  may  be  mistaken  for  reduplica- 
tion of  the  first  sound.  True  reduplication  of  this  sound  is  irrespect- 
ive of  the  element  of  impulsion,  being  due  to  the  disconnection  of 
the  tricuspid  and  valvular  elements  which  enter  into  its  composition. 
When  both  sounds  are  doubled,  the  sounds  succeed  each  other  so 
rapidly  that  the  systolic  and  diastolic  are  hardly  distinguishable  by 
means  of  rhythm,  duration,  etc.  In  the  case  which  came  under  my 
observation,  there  were  over  one  hundred  and  sixty  double  sounds, 
or  more  than  three  hundred  and  twenty  single  sounds  per  minute ! 
The  fact  of  reduplication  in  such  cases  is  to  be  determined  by  com- 
parison of  the  number  of  sounds  with  the  apex-beat,  if  perceptible, 
or  with  the  radial  pulse.  It  is  true  that  the  apex-beat  and  the 
pulse,  in  certain  cases  of  cardiac  disease,  do  not  correspond  with 
the  heart-sounds  when  the  latter  are  not  reduplicated ;  but  when, 

'  lu  connection  vritli  these  remarks,  the  reader  is  referred  to  tlie  analytical  de- 
composition of  the  two  sounds  of  the  heart  into  1st,  an  aortic  and  a  pulmonic  val- 
vular element  composing  the  second  sound  ;  2d,  and  a  tricuspid  valvular  element, 
a  mitral  valvular  element,  and  an  element  of  impulsion  composing  the  first  sound. 
Vide  Chapter  I.,  page  58. 


EEDUPLICATION    OF    HEART-SOUjSTDS.  281 

as  in  the  case  reported  by  me,  the  pulse  is  found  regularly  to  bear 
to  the  heart-sounds  precisely  the  relation  of  one  to  four,  redupli- 
cation is  to  be  inferred.  If  neither  the  pulse  nor  apex-beats  are 
sufficiently  appreciable  to  be  enumerated,  reduplication  of  the  two 
sounds  can  hardly  be  discriminated  with  certainty  from  excessive 
rapidity  of  the  heart's  action.  This  was  the  case  for  the  first  day 
or  two  in  the  instance  which  came  under  my  observation.  In  this 
instance  the  reduplication  was  singularly  regular  and  persisting. 
Generally  it  is  transient,  occurring  at  irregular  intervals,  and  vary- 
ing in  duration.  The  sounds  may  be  tripled  at  one  time  and 
cjuadrupled  at  another  time,  a  fact  readily  explained  by  the  differ- 
ence in  the  intensity  of  the  heart's  action  at  different  periods. 

The  limited  pathological  import  of  reduplications  of  the  heart- 
sounds,  and  of  their  diagnostic  significance,  are  sufficiently  apparent 
from  the  facts  which  have  been  presented.  They  occur  in  cases  of 
organic  disease  of  the  heart,  and  probably  never  unless  organic 
disease  be  present.  But  they  do  not  occur  exclusively  in  connec- 
tion with  any  particular  lesions  irrespective  of  enlargement.  Their 
value  in  diagnosis  is  therefore  small.  As  a  physical  sign  Bouillaud 
calls  it  Mu  signe  de  luxe,  from  its  superfluousness  in  diagnosis.  As 
an  aberration  of  the  heart's  action,  it  does  not  appear  to  be  followed 
by  any  serious  consequences.  It  does  not  render  the  prognosis 
more  unfavorable.  In  the  case  observed  by  me  of  reduplication 
of  both  sounds,  the  patient  recovered  in  a  few  weeks  from  this  form 
of  disorder,  and  remained  perfectly  well,  notwithstanding  moderate 
hypertrophy,  for  several  years,  dying  at  length  of  a  disease  foreign 
to  the  heart.  In  the  case  reported  by  M.  Pressat,  the  patient  was 
sufficiently  restored  in  a  short  time  to  leave  the  hospital.  It  must 
be  confessed  that,  with  our  present  knowledge  of  the  subject  of 
reduplications,  the  interest  belonging  to  it,  if  the  antithesis  be  al- 
lowable, is  rather  scientific  than  practical. 

The  treatment  will  have  relation  entirely  to  the  nature  and  extent 
of  the  coexisting  cardiac  lesions,  together  with  the  associated  symp- 
toms, etc.  In  this  point  of  view,  the  subject  does  not  claim  con- 
sideration. 


CHAPTER   VII. 

INFLAMMATORY   AFFECTIONS    OF   THE   HEART.— 
PERICARDITIS. 

Acute  pericarditis— Anatomical  characters — Division  into  three  stages  or  periods — White 
spots  on  the  heart — Pathological  relations  and  causation  of  pericarditis — Connection 
with  acute  rheumatism,  with  albuminuria  or  Bright's  disease,  with  endocarditis,  etc. — 
Symptoms  of  acute  pericarditis — Symptoms  referable  directly  to  the  heart,  to  the  circu- 
lation, to  the  respiratory  system,  to  the  digestive  system,  to  the  countenance,  position, 
etc.,  to  the  nervous  system — l!^otable  disorder  of  the  brain  and  spinal  cord  in  connection 
with  pericarditis — Physical  signs  of  acute  pericarditis — Signs  furnished  by  percussion, 
by  auscultation,  palpation,  inspection  and  mensuration — Summary  of  the  physical 
signs  of  acute  pericarditis — Diagnosis  of  acute  pericarditis — Prognosis  in  acute  peri- 
carditis— Treatment  of  acute  pericarditis — Bloodletting,  mercurialization,  sedatives, 
revulsives  or  counter-irritants,  opium,  stimulants  and  eliminatives — Treatment  prior  to 
liquid  effusion,  during  the  period  of  liquid  effusion,  and  after  absorption  of  liquid  effu- 
sion— Treatment  when  complicated  with  notable  disorder  of  the  nervous  system — Sub- 
acute and  chronic  pericarditis,  with  and  without  liquid  effusion — Symptoms,  physical 
signs,  and  treatment — Paracentesis  of  the  pericardium — Pneumo-pericardium  and 
pneumo-pericarditis — Pericardial  adhesions — Effects  upon  the  heart  and  circulation — 
Diagnosis. 

IxFLAMMATioN"  affecting  the  heart  may  be  limited  to  one  of  the 
anatomical  structures  which  compose  this  organ.  The  investing 
serous  membrane  may  be  alone  inflamed,  constituting  the  aflfection. 
called  pericarditis,  ^yhen  the  membrane  lining  the  cavities,  or  the 
endocardium,  is  the  seat  of  inflammation,  the  affection  is  called 
endocarditis.  Inflammation  of  the  substance  or  muscular  tissue  of 
the  organ  is  distinguished  as  carditis  or  myocarditis.  Although 
these  different  inflammatory  affections  may  exist,  each  indepen- 
dently of  the  others,  they  are  often  associated. 

In  a  large  proportion  of  the  cases  of  pericarditis,  endocarditis 
coexists ;  and  myocarditis  very  rarely  occurs  save  in  connection 
with  inflammation  of  the  investing  or  lining  membrane  of  the  heart. 
The  intrinsic  importance  of  these  affections  renders  their  study 
highly  important.  They  are  seated  in  an  organ  entitled  to  be  called, 
par  excelloice,  a  vital  organ.  They  involve,  not  infrequently,  great 
suffering  and  imminent  danger  to  life.     They  derive  importance 


ANATOMICAL    CHARACTERS    OF    ACUTE    PERICARDITIS.      283 

from  their  remote  consequences.  The  organic  affections  which 
have  been  considered  in  previous  chapters,  originate,  in  the  majority 
of  instances,  in  cardiac  inflammation.  The  study  of  this  class  of 
affections  has  been  rendered  highly  interesting  and  important  by 
the  developments  of  modern  researches  as  regards  their  pathological 
relations,  especially  to  rheumatism  and  renal  disease,  and  by  the 
improvements  in  diagnosis  arising  from  the  successful  application 
of  physical  methods  of  examination. 


PERICARDITIS. 


Inflammation  affecting  the  investing  membrane  of  the  heart,  or 
pericarditis,  is  less  frequent  in  its  occurrence  than  endocarditis,  but  is 
a  more  serious  affection  as  regards  immediate  danger,  and,  perhaps, 
also  in  view  of  its  remote  effects.  This  membrane  is  analogous 
in  structure  to  serous  tissue  in  other  situations;  and  pericarditis 
does  not  differ  essentially  from  pleuritis  or  peritonitis.  The  points 
of  difference  pertaining  to  the  symptomatic  phenomena  and  the 
dangers  peculiar  to  it,  depend  on  the  comparatively  small  size  of 
the  pericardial  sac,  the  fact  that  the  substance  of  the  heart  consists 
of  muscular  tissue,  the  function  of  the  organ  and  its  physiological 
relations.  In  treating  of  pericarditis,  the  morbid  changes  incident 
to  the  disease,  or  its  anatomical  characters,  are  to  be  first  considered. 
Its  pathological  relations  and  causation  will  next  be  most  conveni- 
ently noticed.  The  symptoms,  physical  signs,  diagnosis,  prognosis, 
and  treatment,  will  severally  receive  distinct  consideration.  This, 
like  other  inflammatory  affections,  is  presented  in  an  acute  and  a 
subacute  or  chronic  form. 

I  shall  treat,  in  the  first  place,  of  acute  pericarditis  under  the 
foregoing  heads,  treating  separately  of  subacute  or  chronic  peri- 
carditis; and,  finally,  the  subject  of  pericardial  adhesions  will  claim 
some  attention. 


Anatomical  Characters  op  Acute  Pericarditis. 

The  morbid  changes  found  after  death  in  fatal  cases  of  pericar- 
ditis, do  not  differ  essentially  from  those  which  belong  to  the  post- 


284         INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

mortem  history  of  other  serous  inflammations.  The  appearances 
vary  according  to  the  stage  of  the  disease  at  which  death  takes 
place.  Death  rarely  occurs  at  the  very  commencement  of  the  in- 
flammatory action.  In  some  instances  in  which  the  disease  has 
proved  rapidly  fatal,  the  serous  surface  has  been  found  more  or 
less  reddened,  mainly  from  injection  of  the  vessels  situated  in  the 
subjacent  areolar  tissue.  The  redness  is  arborescent  and  in  specks  or 
patches,  the  latter  giving  to  the  surface  a  dotted  or  mottled  aspect. 
Mere  redness,  however,  and  vascular  injection  are  not  reliable  as 
the  sole  evidence  of  inflammation. 

The  latter  may  be  due  to  various  causes  which  impede  the  circu- 
lation in  the  heart  shortly  before,  or  at  the  time  of  death ;  and  the 
former  may  be  produced  after  death  by  extravasated  serum  colored 
with  the  h^ematin  of  the  blood  globules.  On  the  other  hand,  the 
redness  which  belongs  to  inflammation,  here,  as  in  other  situations, 
may  have  existed  during  life  and  disappeared  after  death.  Opacity 
of  the  membrane,  alteration  in  its  consistence,  or  the  presence  of 
lymph,  are  essential  to  constitute  proof  positive  that  inflammation 
has  existed.  Abnormal  dryness  of  the  membrane  has  been  sup- 
posed to  be  an  effect  of  incipient  inflammation,  and,  immediately 
succeeding  this,  a  glutinous  or  sticky  sensation,  communicated  to 
the  finger  when  passed  over  the  surface.  The  latter  condition,  from 
its  resemblance  to  that  of  some  fishes  when  they  have  been  several 
hours  out  of  water,  has  been  called  by  French  writers,  poissonneux. 
These  signs,  however,  as  well  as  vascularity  and  redness  in  specks  or 
patches,  are  not,  in  themselves,  sufficient  anatomical  evidence  of 
pericarditis.  They  derive  their  claim  to  be  included  among  the 
anatomical  characters  of  the  disease,  from  their  association  with  the 
ante-mortem  history,  and  with  other  post-mortem  appearances  which 
are  unequivocal  in  their  significance.  Acute  inflammation  speedily 
leads  to  the  exudation  of  coagulable  lymph.  This  exudation  takes 
place  sufficiently  to  give  rise  to  the  characteristic  solid  deposit,  in 
most  cases,  probably,  within  a  few  hours  from  the  commencement 
of  the  inflammatory  attack.  The  deposit,  at  first,  of  a  jelly-like 
consistence,  adheres  slightly  to  the  membrane,  forming  a  thin  layer, 
either  limited  to  the  base  of  the  organ  and  about  the  roots  of  the 
large  vessels,  or  extending,  more  or  less,  over  the  pericardial  sur- 
face. The  heart,  at  this  stage,  covered  with  thin,  soft  lymph,  pre- 
sents an  appearance  which  has  been  compared  to  hoar  frost,  or  to  a 
"layer  of  liquid  gelatine  spread  upon  the  parts  with  a  camel's  hair 
pencil."     The  process  of  exudation  goes  on,  and  the  uncoagulable 


STAGES    OF    ACUTE    PEEICARDITIS.  285 

or  serous  portion  forms  a  liquid  which  accumulates  within  the  peri- 
cardial sac.  If  the  disease  do  not  prove  fatal  during  this  period, 
the  liquid  is  gradually  resorbed,  and  adhesion  of  the  pericardial 
surfaces  brought  into  apposition  follows. 

It  suffices  to  divide  the  disease  into  three  stages,  the  division 
being  based  on  the  series  of  morbid  events  just  mentioned.  The 
brief  period  during  which  the  membrane  is  supposed  to  be  dry, 
or  when  a  glutinous  exudation  is  appreciable  by  the  touch  and  not 
by  the  eye,  is  by  some  reckoned  as  the  first  or  dry  stage.  Practi- 
cally, this  division  is,  to  say  the  least,  superfluous.  The  first  stage 
may  be  considered  as  extending  to  the  time  when  the  accumulation 
of  liquid  is  sufficient  to  be  determinable  during  life  by  symptoms 
and  physical  signs.  The  second  stage  will  embrace  the  period 
during  which  an  appreciable  amount  of  liquid  continues.  The 
third  stage  comprises  the  duration  of  the  disease  after  resorption  of 
the  liquid.  These  stages  may  be  called,  respectively,  the  stage  of 
exudation,  of  liquid  effusion,  and  of  adhesion.  These  terms,  how- 
ever, are  open  to  criticism,  and  a  more  simple  mode  is  to  speak  of 
the  disease  as  consisting  of  three  periods,  viz.,  before,  during,  and 
after  liquid  effusion,  the  latter  expression  being  understood  as 
applying  to  a  quantity  of  effused  liquid  sufficient  to  distend,  more 
or  less,  the  pericardial  sac. 

If  the  disease  end  fatally  during  the  first  period,  or  before  much 
accumulation  of  liquid  takes  place,  the  heart  presents  a  coating  of 
lymph,  varying  in  different  cases  in  its  thickness  and  extent  of 
diffusion.  The  deposit  is  more  apt  to  be  present  and  is  more 
abundant  at  the  base  than  over  the  other  portions  of  the  organ.  It 
may  be  situated  on  both  the  visceral  and  parietal  surfaces  of  the 
pericardium,  or  it  may  be  limited  to  the  former.  It  is  very  rarely, 
if  ever,  found  exclusively  on  the  parietal  surface.  The  lymph  is 
soft,  slightly  adherent,  being  very  easily  removed,  and  presents,  in 
different  cases,  diversities  of  appearance  which  subsequently  become 
more  marked,  and  will  be  presently  noticed.  The  membrane  is 
more  or  less  opaque,  and  may  present  the  arborescent  and  dotted 
redness  already  mentioned.  The  latter,  however,  are  often  wanting 
after  death.  In  some  instances,  when  the  deposit  of  lymph  has 
been  removed,  the  general  aspect  of  the  organ  is  not,  in  a  marked 
degree,  morbid ;  in  some  instances,  the  membrane  covering  the 
heart  is  studded  with  prominences  resembling  the  enlarged  papil- 
lary bodies  on  the  tongue ;  in  other  words,  it  presents  a  mamraillated 
aspect.     The  opacity  is  due  to  infiltration  beneath  the  membrane ; 


286         INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

and  this  infiltration  loosens  the  attachment  of  the  membrane,  so 
that  it  is  detached  from  the  heart  with  greater  facility  than  in  the 
normal  condition  of  the  organ.  The  exudation  within  the  sac,  in 
some  instances,  consists  almost  entirely  of  coagulable  lymph,  and 
an  amount  of  liquid  sufficient  to  be  determinable  does  not  occur 
during  the  progress  of  the  disease.  The  affection  in  these  cases  is 
analogous  to  dry  pleurisy ;  and  they  have  been  called  cases  of  dry 
pericarditis.  It  is,  however,  rare  for  inflammation  diffused  over 
the  pericardial  surfaces,  in  other  words,  general  pericarditis,  to  run 
its  course  without  giving  rise  to  considerable  liquid  effusion. 
When  this  effect  does  not  occur,  the  inflammation  is  generally 
partial,  that  is,  limited  to  a  circumscribed  portion  of  the  membrane. 
This  remark  holds  good  equally  with  respect  to  pleurisy. 

The  accumulation  of  liquid  sufficiently  to  be  manifested  by  signs 
and  symptoms,  takes  place  at  a  period  from  the  commencement  of 
the  disease,  varying  in  different  cases.  The  quantity  becomes 
sometimes  large  enough  to  occasion  distension  of  the  pericardial 
sac  in  twenty-four  or  thirty-six  hours  from  the  date  of  the  attack. 
In  the  majority  of  cases,  three  or  four  days  elapse  before  this 
occurs.  As  just  stated,  in  some  exceptional  cases  it  does  not  take 
place  during  the  whole  career  of  the  disease.  The  amount  of 
effusion  also  varies  greatly  in  different  cases.  From  four  to  six 
ounces  of  liquid  may  be  determinable  in  some  cases;  and  the 
quantity  which  may  accumulate  beyond  this  amount  ranges  from 
a  few  additional  ounces  to  as  many  as  eight  pounds.  A  case  is 
reported  by  Corvisart,  and  also  one  by  Dr.  Swett,'  in  which  the 
accumulation  attained  to  the  maximum  just  stated.  The  distension 
in  these  cases  was  enormous,  exceeding  several  times  the  limit  to 
which  the  healthy  sac  is  capable  of  being  dilated  by  forcible  injec- 
tion of  a  liquid  after  death.  Experiments  made  by  Dr.  Sibson  to 
determine  the  latter  point  showed  that,  in  the  adult  male  at  fifty 
years  of  age,  the  injection  of  twenty-two  ounces  of  liquid  dilated 
the  sac  to  its  utmost  capacity.^  Yery  great  accumulation  belongs 
rather  to  chronic  than  acute  pericarditis.  The  quantity  in  the 
latter  rarely  exceeds  two  or  three  pints.  The  effused  liquid  is 
more  or  less  turbid.  It  is  sometimes  transparent  at  the  surface, 
resembling  clear  serum,  but  muddy  and  thick  at  the  bottom.  The 
turbidity  proceeds  from  the  admixture  of  lymph,  and  detached 

'  Lectures  on  Diseases  of  the  Chest. 
*  Bellingham,  op,  cit,,  Part  I.,  p.  22. 


ANATOMICAL    CHARACTERS    OF    ACUTE    PERICARDITIS.      287 

portions  of  the  latter  in  flocculi  or  shreds  are  found  in  greater  or 
less  quantity  at  the  dependent  portion  of  the  sac.  This  turbidity 
and  the  presence  of  flakes  of  lymph  distinguish  inflammatory  effu- 
sion from  the  transudation  which  constitutes  simple  dropsy  in  this 
situation  or  hydro-pericardium.  Occasionally,  the  liquid  effused  in 
pericarditis  is  sanguinolent,  the  blood  probably  being  derived  from 
the  rupture  of  vessels  in  newly-organized  structure.  Laennec  con- 
sidered this  as  a  variety  of  pericarditis,  which  he  called  hemor- 
rhagic. The  admixture  of  lymph  sometimes  renders  it  puruloid ; 
and  in  some  very  rare  instances  the  liquid  may  be  truly  purulent. 
In  these  instances  the  disease  bears  to  ordinary  pericarditis  the 
same  relation  as  empyema  to  ordinary  pleurisy. 

In  the  majority  of  cases  in  which  acute  pericarditis  proves  fatal 
per  se,  death  occurs  during  the  period  of  liquid  effusion.  On  ex- 
amination post-mortem,  the  pericardial  sac  is  found  to  contain  a 
certain  quantity  of  turbid,  puruloid,  sanguinolent,  or  purulent 
liquid.  The  free  surface  of  the  sac,  especially  upon  the  heart, 
presents,  in  different  cases,  diversities  of  appearance,  due  to  the 
quantity  and  disposition  of  the  exuded  lymph.  The  deposit  is 
more  abundant  than  it  was  prior  to  the  liquid  effusion.  It  has 
become  more  dense  and  more  firmly  adherent  to  the  membrane. 
It  is  frequently  laminated.  Extending,  in  some  cases,  over  the 
whole  heart,  or  confined  to  certain  portions,  it  forms  a  covering  of 
variable  thickness,  which  often  has  a  reticulated  appearance  re- 
sembling gauze  or  lace-work ;  or,  quoting  comparisons  by  different 
observers,  the  appearance  is  frequently  not  unlike  that  of  the 
section  of  a  sponge,  the  interior  of  the  gall-bladder,  the  second 
stomach  of  the  calf,  or  a  congeries  of  small  earth  worms.  In  other 
instances  the  lymph  is  rolled  into  ridges,  giving  to  the  surface  of 
the  heart  a  furrowed  or  wrinkled  aspect.  These  ridges  are  so 
disposed  in  some  cases  as  to  give  rise  to  an  appearance  which  has 
been  compared,  poetically,  by  Hope  to  the  undulations  of  sand  on 
the  sea-shore.  Another  disposition  of  the  lymph  is  in  the  form  of 
villous  projections,  giving  to  the  exterior  of  the  heart  a  shaggy 
appearance.  In  a  specimen  which  I  have,  the  entire  surface  of  the 
organ  is  covered  with  closely  set,  fine  filaments  from  two  to  four 
lines  in  length.  This  peculiar  appearance  probably  is  that  to 
which  was  applied  formerly  the  name  cor  villosum,  or  hairy  heart. 
Another  variety  still  is  the  deposit  of  lymph  in  minute  patches, 
thickly  disseminated  over  the  heart's  surface.  The  diversities  of 
appearance  are  explained  by  the  movements  of  the  visceral  and 


288  INFLAMMATORY    AFFECTIOXS    OF    THE    HEART. 

parietal  surfaces  of  the  membrane  upon  each  other,  caused  by  the 
elongation  and  rotation  of  the  heart  during  its  systole.  They  may 
be  rudely  imitated,  as  Laennec  remarks,  by  rubbing  together  and 
alternately  bringing  into  contact  and  separating  two  marble  slabs, 
their  surfaces  having  been  covered  with  a  layer  of  soft  butter. 
When  the  pericardial  sac  is  distended  with  liquid,  the  two  surfaces 
may  come  together  at  certain  points  during  the  systole,  and  recede 
during  the  diastole.  It  is  evident  that  this  cannot  occur  when  the 
pericardial  sac  is  empty ;  the  two  surfaces  must  then  be  constantly 
in  contact,  friction  of  the  surfaces  only  taking  place,  without  sepa- 
ration. The  deposit  of  lymph,  as  already  stated,  may  be  general 
or  limited  to  certain  situations.  It  is  most  prone  to  accumulate 
near  the  base  and  about  the  large  arteries  at  their  origin.  It  may 
be  found  exclusively  or  most  abundant  on  either  the  anterior  or 
posterior  surface  of  the  organ.  It  is  rarely  very  abundant  on  the 
parietal  -surface  of  the  membrane. 

When  death  does  not  occur  during  the  period  of  the  continuance 
of  an  abundant  liquid  effusion,  the  latter  is  removed,  sometimes 
quite  rapidly,  and  in  other  cases  slowly,  by  absorption,  and  the 
pericardial  surfaces  again  come  into  apposition.  In  examinations 
after  death,  at  a  period  somewhat  remote  from  this  occurrence, 
these  surfaces  are  found  united.  Adhesion  has  taken  place.  This 
may  be  either  mechanical  or  by  means  of  organization.  In  some 
specimens  the  parietal  portion,  together  with  the  fibrous  sac,  is 
simply  agglutinated  to  the  heart  with  a  certain  force,  and,  when 
detached,  successive  layers  of  condensed  lymph  are  found  to  inter- 
vene between  this  portion  and  the  exterior  of  the  organ.  These 
layers  may  sometimes  be  peeled  ofT,  one  after  the  other,  presenting 
the  appearance  of  distinct,  firm  membranes.  Those  nearest  the 
heart  are  sometimes  reddened  with  hsematin.  Collectively,  they 
form  a  mass  which  may  be  nearly  or  quite  an  inch  in  thickness. 
This  mode  of  adhesion  is  purely  mechanical.  These  layers  of 
lymph  never  take  on  organization.  They  are  correctly  called  false 
membranes.  It  is  doubtful  if,  under  these  circumstances,  the  or- 
ganized adhesion  ever  occurs.  The  quantity  of  fibrin  prevents  this 
result.  But  in  other  instances,  in  which  the  intervening  deposit  of 
lymph  is  less  abundant  and  dense,  newly-organized  structures  are 
formed,  and  adhesion  by  a  vital  union  takes  place.  The  pericardial 
sac  may  be  in  this  way  completely  obliterated.  It  was  probably 
cases  of  this  kind  which,  coming  under  the  observation  of  some  of 
the  old  anatomists,  led  them  to  conclude  that  the  pericardium  was 


ANATOMICAL    CHARACTERS    OF    ACUTE    PERICARDITIS.       289 

sometimes  wantiag.  Union  by  an  organized  attachment  may  be 
partial.  Sometimes  it  is  limited  to  certain  points,  and,  the  newly 
organized  structure  becoming  elongated  by  the  movements  of  the 
heart,  the  opposing  surfaces  are  connected  by  membranous  bridles 
or  bands.  The  pericardial  surfaces  may  become  firmly  adherent 
over  one  side  of  the  heart,  and  the  remainder  of  the  sac  contain  a 
considerable  quantity  of  liquid.  Two  examples  of  this  kind  have 
fallen  under  my  observation.  In  one,  adhesion  had  occurred  over 
the  left  half  of  the  organ,  and  the  quantity  of  liquid  contained  in 
the  right  half  of  the  sac  was  so  great  as  to  extend  far  beyond  the 
right  margin  of  the  sternum,  giving  rise  to  physical  signs  which 
were  supposed  to  denote  effusion  into  the  right  pleural  cavity.  In 
the  other,  the  adhesion  was  over  the  right  side,  and  the  accumulation 
of  liquid  in  the  left  half  of  the  pericardial  sac  gave  rise  to  a  tumor 
which  projected  far  beyond  the  left  border  of  the  heart.  The  pro- 
cess of  adhesion  may  be  completed  within  a  period  varying  from  a 
few  days  to  several  weeks.  The  strength  of  the  adhesion  is  a  test 
of  its  age.  When  recent,  the  attachment  is  easily  broken,  but  it 
becomes  extremely  firm  after  the  lapse  of  considerable  time.  The 
metamorphoses  which  take  place  in  the  deposit  of  lymph  in  certain 
cases,  belong  more  appropriately  to  the  anatomical  history  of  chro- 
nic pericarditis,  and  will  be  noticed  in  that  connection. 

In  examinations  after  death  of  bodies  dead  with  various  diseases, 
the  symptoms  during  life  not  having  pointed  to  the  existence  of 
any  cardiac  affection,  one  or  more  opaque  patches  are  often  found 
on  the  heart,  generally  situated  on  the  anterior  portion  of  the  right 
ventricle,  near  the  middle  or  toward  the  base  of  the  organ.  These 
are  the  white  or  milk  spots  [maculce  alhidce  vel  ladece)  which  have 
given  rise  to  considerable  discussion  among  pathologists.  They 
vary  in  size  from  that  of  a  half  dime  to  a  quarter  of  a  dollar. 
Their  form  is  variable,  being  round,  oval,  or  irregular  in  their  con- 
tour, and  sometimes  linear.  The  question  is,  To  what  extent  are 
they  to  be  considered  as  evidence  of  ancient  pericarditis?  They 
consist,  in  nearly  all  the  instances  in  which  I  have  examined  with 
reference  to  this  point,  of  lymph  deposited  in  a  thin  layer,  closely 
adhering,  but  which  may  be  stripped  off,  leaving  the  surface  of  the 
heart  beneath  normal,  except  that  it  has  lost  somewhat  of  its  natu- 
rally smooth  and  polished  appearance.  It  is  stated,  however,  that 
in  some  instances  they  proceed  from  opacity  and  thickening  of  the 
membrane  itself.  That  they  result  from  inflammation  when  they 
are  due  to  a  deposit  of  lymph,  must  be  admitted.  They  constitute 
19 


290  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

evidence  of  partial  or  circumscribed  pericarditis,  but  so  limited  in 
extent  as  not  to  give  rise  to  any  symptoms  of  disease  or  any  evil 
consequences.  Practically,  they  are  of  no  importance.  They  are 
undoubtedly  due  to  some  local  cause;  and  the  most  probable  ex- 
planation is  that  given  by  Dr.  Hodgkin  and  others,  which  attributes 
them  to  the  attrition  between  the  anterior  surface  of  the  heart  and 
the  thoracic  walls.  When  the  membrane  itself  is  thickened,  they 
are  probably  a  kind  of  callosity  caused  by  pressure.  They  are 
rarely  found  in  subjects  under  the  age  of  puberty,  but  very  fre- 
quently after  forty;  and  they  are  much  more  common  in  males 
than  in  females. 


Pathological  Relations  and  Causation  of  Pericarditis. 

Acute  pericarditis,  as  an  idiopathic  or  primary  disease,  is  ex- 
tremely rare.  The  chances  of  its  development,  irrespective  of  any 
other  disease,  in  a  healthy  person,  are  very  few.  In  this  respect  it 
may  be  classed  with  acute  gastritis  and  meningitis  in  the  adult. 
In  the  vast  majority  of  cases  it  is  a  secondary  affection.  It  is 
developed  either  as  a  complication  of  some  other  affection,  or  in 
connection  with  some  one  of  the  diseases  called  general,  or  of  the 
cachexite.  It  is  understood,  of  course,  that  this  remark  does  not 
apply  to  traumatic  cases.  The  pathological  relations  of  pericarditis, 
therefore,  in  this  point  of  view,  form  an  important  as  well  as  inte- 
resting portion  of  the  etiological  history  of  the  disease.  The  affec- 
tions of  which  it  is  an  occasional  concomitant  are  numerous,  but 
in  much  the  larger  proportion  of  instances  it  occurs  in  the  course 
of  either  articular  rheumatism  or  renal  affections  involving  albu- 
minuria. 

The  attention  of  clinical  observers  has  been  directed  to  the  occur- 
rence of  pericarditis  in  cases  of  rheumatism  only  within  the  last 
thirty  years.  The  occasional  association  of  these  affections  was 
noticed  by  Pitcairn  in  1788,  Dundas  in  1809,  and  by  Dr.  Wells  in 
1812;  but  the  existence  of  a  pathological  relation  between  them 
was  not  fully  recognized  prior  to  the  publications  of  Dr.  Latham 
and  Dr.  Elliotson  in  1829.  The  subsequent  observations  of  Bouil- 
laud,  Ilope,  and  others,  established  the  fact  that,  in  a  large  propor- 
tion of  the  cases  of  pericarditis,  the  disease  occurs  in  connection 
with  rheumatism.  Although  it  is  observed  much  less  frequently 
than  endocarditis  in  this  connection,  the  proportion  of  the  cases  of 


PERICARDITIS    IN    RHEUMATISM.  291 

acute  rheumatism  in  wliicli  it  becomes  developed  is  tolerably  large. 
Of  847  cases  collected  from  various  sources  and  analyzed  by  Dr. 
Fuller,  it  existed  in  l-i2.  being  in  a  ratio  of  about  1  to  every  6 
cases.    These  cases  were  reported  by  six  trustworthy  observers,  and 
it  is  worthy  of  note  that  each  collection  of  cases  gives  not  far  from 
the  same  ratio  as  when  they  are  analyzed  collectively.'    Of  19  cases 
of  recent  pericarditis,  the  histories  of  which,  recorded  by  myself, 
are  before  me,  in  6  the  affection  occurred  manifestly  in  connection 
with  rheumatism.     Statistics  show  that  rheumatism  is  more  likely 
to  become  complicated  with  pericarditis  in  proportion  to  the  youth 
of  the  patients  affected.     Thus,  Dr.  Fuller  deduces  from  cases  re- 
ported by  different  observers  that  it  occurs  in  a  ratio  of  more  than 
one-third  under  the  age  of  15 ;  of  a  little  less  than  one-fifth  between 
the  ages  of  15  and  20;  of  less  than  one-tenth  between  20  and  25; 
whilst  above  the  age  of  25  the  ratio  diminishes  with  even  greater 
rapidity.     A  decided  influence,  therefore,  in  the  production  of  the 
disease,  in  this  connection,  pertains  to  age.    It  appears  also  to  occur 
in  a  larger  ratio  in  females  than  in  males.^    The  liability  to  pericar- 
ditis appears  to  be  greater,  other  things  being  equal,  in  proportion 
to  the  acuteness  and  severity  of  the  rheumatic  attack,  as  denoted 
by  the  intensity  of  the  local  symptoms  and  the  febrile  movement. 
It  is  rarely  developed  in  the  subacute  form  of  the  latter  affection ; 
the  chronic  form,  and  the  affection  called  muscular  rheumatism,  do 
not  involve  a  liability  of  its  occurrence,  and  the  same  may  be  said 
of  gout.     It  has  been  observed  to  become  developed  oftener  in  the 
first  than  in  subsequent  attacks  of  rheumatism.     It  may  occur  at 
any  period  during  the  course  of  the  rheumatic  affection,  but  in  the 
majority  of  cases  it  is  developed  between  the  fourth  and  twelfth 
days.     Several  instances  have  been  reported  in  which  it  preceded 
the  affection  of  the  joints;  I  have  met  with  one  instance  of  this 
kind,  and  in  one  case  which  came  under  my  observation  it  occurred 
coincidently  with  an  affection  of  the  wrist.    According  to  Dr.  West, 
it  oftener  takes  precedence  of  the  affection  of  the  joints,  and  is 
more  apt  to  occur  coincidently  with,  or  shortly  after,  the  latter,  in 
children  than  in  adults.^ 

What  is  the  nature  of  the  pathological  relation  existing  between 
pericarditis  and  acute  rheumatism  ?    After  the  fact  of  a  relation  was 

'  On  Rheumatism,  Rheumatic  Gout,  and  Sciatica.     By  Heury  William  Fuller, 
M.  D.,  etc.     Am.  edition,  1854,  p.  216. 
2  Fuller,  op.  cit. 
^  On  Diseases  of  Children,  second  American  edition,  p.  304. 


292  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

ascertained,  it  was  supposed  that  a  transference  of  the  disease  from 
the  joints  to  the  heart  took  place,  and  that  the  pericarditis  was  due 
to  change  of  seat,  or  metastasis.  This  view  is  disproved  by  the  fact 
that  the  inflammation  of  the  pericardium  does  not  involve  neces- 
sarily, nor  indeed,  generally,  diminution  of  the  articular  inflam- 
mation. The  reverse  of  this  obtains  in  the  majority  of  cases. 
Moreover,  as  has  just  been  stated,  the  pericarditis  in  some  instances 
precedes  the  affection  of  the  joints.  The  same  internal  morbid  con- 
dition which  determines  the  latter,  gives  rise  to  the  former.  The 
one,  as  well  as  the  other,  is  the  local  expression  of  a  general  or 
constitutional  afiection,  involving,  probably,  blood-changes,  in  which 
consists  the  essential  pathology  of  rheumatism.  The  pericarditis 
and  the  affection  of  the  joints,  in  other  words,  are,  alike,  effects  of  a 
common  pathological  condition. 

To  inquire  respecting  the  nature  of  the  blood-changes  which 
constitute  this  condition,  does  not  fall  within  the  scope  of  this  work. 
As  the  affection  of  the  joints  in  rheumatism  exists  in  the  larger 
proportion  of  cases  without  the  development  of  pericarditis,  so  it 
is  probable  that  rheumatic  pericarditis  may  sometimes  occur  with- 
out the  former.  The  liability  of  the  pericardial  membrane  to  become 
the  seat  of  inflammation  in  rheumatism,  is  to  be  explained  by  the 
analogy  of  structure  between  this  membrane  and  the  tissues  enter- 
ing into  the  composition  of  the  articulations. 

Since  our  knowledge  of  the  connection  of  albuminuria  with  cer- 
tain affections  of  the  kidney  dates  from  the  researches  of  Bright, 
published  in  1827,  it  follows  that  the  pathological  relation  existing 
between  pericarditis  and  these  affections  has  but  recently  been 
ascertained.  Clinical  observation  within  late  years  has  abundantly 
established  the  existence  of  such  a  relation.  Of  35  cases  of  peri- 
carditis analyzed,  with  respect  to  causation,  by  Dr.  John  Taylor, 
Bright's  disease  existed  in  13,  and  the  development  of  the  pericar- 
dial inflammation  could  not  otherwise  be  accounted  for.^  Of  19 
cases  taken  from  my  records,  Bright's  disease,  or  marked  albumi- 
nuria, was  present  without  any  other  apparent  causative  agency, 
in  3,  and  probably,  also,  in  2  additional  cases.  On  the  other  hand, 
of  50  patients  who  had  either  died  of  Bright's  disease,  or  who  were 
ascertained  to  have  this  disease  in  an  advanced  form,  acute  pericar- 
ditis was  found  by  Dr.  Taylor  in  5,  or  in  the  ratio  of  1  to  10.     Of 

■  On  Some  of  the  Causes  of  Pericarditis.  Medico-Chirurgical  Transactions,  vol. 
xxviii.  p.  453. 


PEEICARDITIS    IN    BRIGHT's    DISEASE.  293 

135  fatal  cases  of  pericarditis  analyzed  by  Dr.  T.  K.  Chambers,  the 
kidneys  were  diseased  in  36/  In  a  collection  of  cases  of  pericarditis, 
including  cases  which  recover  as  well  as  those  which  prove  fatal, 
the  disease  is  found  to  be  developed  much  oftener  in  connection 
with  acute  rheumatism  than  with  an  affection  of  the  kidneys.  But 
in  a  collection  of  fatal  cases  of  pericarditis,  renal  disease  is  found 
to  coexist  much  oftener  than  acute  rheumatism.  The  explanation 
of  this  is,  pericarditis  developed  in  connection  with  Bright's  disease 
especially  at  an  advanced  stage  of  this  disease,  almost  invariably 
ends  fotally;  whilst  in  connection  with  acute  rheumatism,  recovery 
takes  place  in  a  large  proportion  of  instances. 

What  is  the  nature  of  the  pathological  relation  existing  between 
pericarditis  and  the  renal  affections  generally  included  under  the 
name  of  Bright's  disease?  Clinical  observation  shows  that,  in  con- 
nection with  the  latter,  serous  inflammations  are  apt  to  become 
developed.  The  production  of  these  inflammations,  as  well  as  other 
effects,  are  attributed  to  the  accumulation  of  urinary  principles  in 
the  blood,  in  consequence  of  the  impaired  excretory  function  of  the 
kidneys.  The  intermediate  morbid  condition  determining  the  peri- 
carditis, is  thus  supposed  to  be  urasmia.  The  urea  in  excess,  or 
the  products  of  its  decomposition  in  the  blood,  act  as  poisonous 
agents,  giving  rise  to  inflammation  of  the  pericardial  and  other  serous 
membranes,  among  various  pathological  consequences.  This  is  the 
explanation  most  consistent  with  our  present  knowledge. 

Pericarditis  is  frequently  associated  with  either  pleuritis  or 
pleuro-pneumonia.  It  has  been  inferred  from  this  association  that 
the  inflammation  extends  from  the  pulmonary  organs  to  the  heart, 
in  consequence  of  the  proximity  of  the  latter  to  the  former,  an 
inference  which  appears  to  be  strengthened  by  the  fact  that  the 
coexisting  inflammation  of  the  pulmonary  structures  is  situated  on 
the  left,  oftener  than  on  the  right  side.  But  pleuritis  and  pleuro- 
pneumonia are  diseases  of  frequent  occurrence,  and  in  the  great 
majority  of  cases  the  inflammation  does  not  extend  to  the  pericar- 
dium. On  the  other  hand,  in  cases  of  pericarditis  developed  in 
connection  with  acute  rheumatism,  the  inflammation  very  rarely 
extends  to  the  adjoining  pulmonary  structures.  It  is  chiefly  in 
non-rheumatic  cases  of  pericarditis  that  this  disease  is  associated 
with  pulmonary  inflammation.  It  is,  therefore,  more  rational  to 
conclude  that  between  the  latter  and  the  former  there  exists  no 

'  Decenniuin  Patlioloaficum. 


291  INFLAMMATORY    AFFECTIONS    OF    THE    IIEAET. 

relation  of  causation,  but  that  both  are  equally  dependent  on 
some  internal,  determining  pathological  condition.  This  condition 
belongs,  in  a  certain  proportion  of  cases,  to  disease  of  the  kidney, 
and,  in  other  cases,  to  some  of  the  diseases  occasionally  giving  rise 
to  pericarditis,  which  are  presently  to  be  noticed.  Although  it  is 
true  that  when  pleuritis  is  associated  with  pericarditis  the  left 
jDleura  is  oftener  affected  than  the  right,  yet  the  right  pleura  is  not 
infrequently  the  seat  of  the  inflammation.  Of  seven  fatal  cases,  of 
which  I  have  preserved  notes,  the  right  side  was  affected  in  three. 
The  pleuritis  was  double  in  three  of  these  cases.*  To  show  the 
relative  frequency  of  the  occurrence  of  pleurisy  and  pneumonia  in 
cases  of  non-rheumatic  as  compared  with  rheumatic  pericarditis, 
the  following  statistics  by  Dr.  Taylor  may  be  cited :  In  24  cases  of 
non-rheumatic  pericarditis,  pneumonia  occurred  in  12,  while  it 
occurred  in  only  4  of  16  cases  of  rheumatic  pericarditis.  Pleurisy 
occurred  in  10  of  16  cases  of  the  former,  and  in  only  7  of  24  cases 
of  the  latter. 

Pyasmia  appears  to  rank  next  to  Bright's  disease  as  regards  the 
frequency  of  its  coexistence  with  pericarditis  in  fatal  cases  of  the 
latter.  It  existed  in  18  of  the  135  subjects  examined  by  Dr. 
Chambers,  a  ratio  equal  to  that  of  rheumatism  in  this  collection  of 
cases.  Pyaemia,  at  the  same  time,  is  likely  to  give  rise  to  inflam- 
mation affecting  serous  structures  in  other  situations.  It  is  proba- 
bly through  the  intervention  of  this  blood  affection  that  wounds  of 
parts  remote  from  the  heart  and  surgical  operations  sometimes 
give  rise  to  pericarditis.  Of  the  nature  of  the  pathological  relation 
existing  between  pyaemia  and  pericarditis  all  that  can  be  said  with 
our  present  knowledge  is,  that  the  blood  is  so  altered  as  to  deter- 
mine, among  other  results,  inflammation  of  the  pericardium. 

The  eruptive  and  continued  fevers  occasionally  become  compli- 
cated with  pericarditis.  It  must  be  extremely  rare  for  this  com- 
plication to  occur  in  connection  with  either  typhoid  or  ty[)hus 
fever ;  but  examples  of  its  development  in  the  course  of  scarlatina 
and  small-pox  are  not  so  uncommon.  When  it  occurs  as  a  sequel 
of  scarlatina,  of  which  I  have  met  with  an  instance,  it  is  probably 
dependent  on  the  morbid  condition  incident  to  albuminuria.  In 
the  instance  just  alluded  to,  it  was  preceded  by  general  dropsy  and 
albuminous  urine.     The  pathological  relation  with  the  essential 

'  Louis'  statistics  show  coexisting  pleuritic  or  pneumonic  inflammation  to  be 
limited  to  the  right  side  in  one-third  of  the  cases  in  which  these  pulmonary  afl'ec- 
tions  are  associated  with  pericarditis. 


PEEICARDITIS    IN    SCURVY,   ETC.  295 

fevers,  also,  involves  certain  internal  causes  pertaining  probably  to 
blood-changes. 

Pericarditis  has  been  observed  to  occur  in  cases  of  scorbutus. 
Its  occurrence  in  this  pathological  connection  was  observed  some 
years  since  during  the  prevalence  of  scurvy  among  sailors  at  St. 
Petersburg  by  M.  Seidlitz,  of  that  city ;  and  a  variety  of  the  disease, 
said  to  be  frequent  on  the  extreme  northern  coasts  of  Europe, 
where  scurvy  is  endemic,  has  been  described  by  M.  Kyber  under 
the  name  of  pericarditis  scorhutica.  Another  observer,  M.  Karawa- 
gan,  found  that  of  sixty  subjects  dead  with  scurvy,  thirty  were 
affected  with  pericarditis.  As  described  by  these  three  writers,  the 
pericarditis  occurring  in  scurvy  differs  from  the  ordinary  form  of 
the  disease,  in  the  bloody  character  of  the  liquid  effusion  contained 
in  the  pericardial  sac.  It  is,  in  fact,  a  species  of  hemorrhagic 
pericarditis.' 

Purpura  and  cyanosis  are  other  affections,  characterized  by  a 
morbid  condition  of  the  blood,  in  connection  with  which  pericar- 
ditis has  been  observed  to  become  .developed.  It  is,  however, 
doubtful  if  the  number  of  instances  in  which  the  association  occurs 
is  sufficient  to  show  the  existence  of  any  special  pathological 
relation. 

Erysipelas  and  influenza  are  affections  in  connection  with  which 
pericarditis  has  been  observed  sometimes  to  become  developed. 

Tuberculosis  of  the  lungs  is  sometimes  associated  with  pericar- 
ditis. Of  eleven  fatal  cases  in  which  the  pericarditis  was  recent, 
pulmonary  tuberculosis  coexisted  in  three.  This  association  is 
probably  due  merely  to  coincidence.  The  tuberculous  cachexia 
does  not  appear  to  give  rise  to  inflammation  of  the  pericardium, 
except  in  the  vevy  rare  instances  in  which  tubercle  is  deposited 
upon  this  membrane.  The  same  remark  is  applicable  to  the  car- 
cinomatous cachexia. 

As  thus  far  considered,  the  causation  of  pericarditis  has,  for  the 
most  part,  involved  internal  morbid  conditions  pertaining  to  cer- 
tain general  diseases,  cachexias  and  blood-changes.  In  the  great 
majority  of  cases,  the  disease  is  developed  secondarily  in  some  of 
these  pathological  relations,  and,  as  already  stated,  more  especially 
in  connection  with  either  acute  rheumatism  or  renal  affections 
accompanied  by  albuminuria.  But  various  local  causes  may  give 
rise  to  the  disease.     It  may  be  produced  by  wounds  penetrating 

'  Bellingliam,  op.  cit,,  Part  II.  p.  263. 


296         INFLAMMATOEY    AFFECTIONS    OF    THE    HEAET. 

the  pericardial  sac,  and  by  other  injuries  of  the  chest.  In  these 
cases  the  disease  is  traumatic.  Abscesses  formed  in  the  liver 
occasionally  open  into  the  pericardial  sac  and  occasion  acute 
inflammation.  Collections  of  softened  tubercle  in  the  lungs  have 
been  known  to  take  this  direction.  Mediastinal  abscesses  may 
pursue  the  same  course.  The  pericardium  sometimes  appears  to 
take  on  inflammation  in  consequence  of  the  local  irritation  excited 
by  aneurismal  tumors  of  the  aorta.  Enlargement  of  the  heart 
probably,  in  some  instances,  leads  to  this  result.  The  deposit  of 
either  tubercle  or  carcinomatous  matter  upon  this  membrane, 
happily  extremely  rare,  is  another  local  cause  to  which  allusion 
has  already  been  made. 

Exclusive  of  the  cases  in  which  pericarditis  is  developed  as  a 
secondary  disease,  i.  e.,  dependent  on  some  antecedent  morbid  con- 
dition, it  may  possibly  occur  as  a  primary  or  idiopathic  affection. 
Instances,  however,  are  so  extremely  rare  that  clinical  observers  of 
large  experience  declare  they  have  never  met  with  an  example. 
On  this  point.  Dr.  Walshe  remarks  that  "alleged  idiopathic  peri- 
carditis becomes  rarer  every  year,  in  proportion  as  the  evolution  of 
diathetic  diseases  grows  more  fully  understood ;"  and  he  adds  that 
he  has  never  seen  a  positive  case  of  the  kind. 

The  influence  of  youth  in  the  causation  of  rheumatic  pericarditis 
has  been  referred  to.  Statistics  show  that  non-rheumatic  cases  em- 
brace a  larger  proportion  of  persons  beyond  the  middle  period  of 
life.  The  average  age  in  twenty-four  cases  of  the  latter,  reported 
by  Dr.  Ormerod,  was  forty-tviro;  while  in  sixty-one  cases  of  the  for- 
mer, the  average  age  was  twenty-one.  This  disparity  is  intelligible 
when  it  is  considered  that,  exclusive  of  acute  rheumatism,  pericar- 
ditis, in  the  majority  of  cases,  is  dependent  on  Bright's  disease,  and 
persons  in  middle  life,  more  than  the  young,  are  liable  to  the  latter. 
But  no  period  of  life  is  positively  exempt  from  the  liability  to  peri- 
carditis. Numerous  cases  have  been  reported  in  which  the  disease 
occurred  in  infants  but  a  few  months  old.  In  some  of  these  cases 
the  most  prominent  symptom  was  screaming  of  the  infant.  I  met 
with  a  case,  several  years  since,  of  the  disease  in  a  child  eight 
months  old,  in  which  this  was  the  chief  symptom,  the  sudden, 
sharp,  brief  cry  resembling  that  which  is  characteristic  of  menin- 
gitis, and  leading  to  a  suspicion  of  the  existence  of  the  latter  affec- 
tion. 

In  a  very  large  proportion  of  cases  of  pericarditis,  endocarditis 
coexists.     In  rheumatic  pericarditis  this  is  a  rule  to  which  there 


SYMPTOMS    OF    ACUTE    PERICAEDITIS.  297 

are  few,  if  any,  exceptions.  The  rule  does  not  hold  good,  at  least 
to  the  same  extent,  in  non-rheumatic  pericarditis.  The  frequent 
association  of  the  two  affections  will  serve,  in  a  measure,  to  account 
for  the  fact  that  when,  on  examination  after  death,  the  evidences  of 
ancient  pericarditis  are  discovered,  the  heart  is  often,  if  not  gene- 
rally, more  or  less  enlarged,  and  valvular  lesions  are,  at  the  same 
time,  found.  The  remote  effects  of  pericarditis  on  the  heart,  is  a 
point  of  interest  and  importance,  which  will  be  considered  in  con- 
nection with  the  subject  of  pericardial  adhesions. 


Symptoms  op  Acute  Pericarditis. 

The  symptoms  of  acute  pericarditis  vary  according  to  the  inten- 
sity of  the  inflammation,  the  amount  of  liquid  effusion,  and  other 
circumstances,  the  effects  of  which  are  sufficiently  manifest.  But, 
irrespective  of  these,  variations  in  different  cases  are  observed, 
which  cannot  be  traced  to  obvious  differences  in  morbid  conditions 
pertaining  to  the  organ  affected.  In  this  respect,  however,  the 
disease  does  not  differ  from  other  inflammations,  especially  those 
affecting  serous  structures.  The  same  is  true  of  pleuritis,  menin- 
gitis, and  peritonitis.  Certain  of  the  symptomatic  phenomena,  such 
as  pain,  febrile  movement,  etc.,  are  present  in  a  marked  degree  in 
some  cases,  in  a  moderate  or  slight  degree  in  other  cases,  and  are 
sometimes  wanting,  when  the  appearances  after  death  denote  equal 
intensity  and  extent  of  the  inflammation.  There  is,  in  short,  often 
an  apparent  want  of  correspondence  between  the  manifestations  of 
the  disease  during  life,  and  the  changes  ascertained  after  death, 
showing  that  the  symptomatic  events  which  belong  to  the  clinical 
history  of  the  disease,  are  influenced,  in  no  small  measure,  by  cir- 
cumstances pertaining  to  other  parts  of  the  body  than  the  organ 
affected,  or  to  the  general  system.  These  circumstances  are  but 
little  understood ;  but  this  remark  is  not  more  applicable  to  peri- 
carditis than  to  various  other  local  affections.  This  frequent  want 
of  harmony  (if  this  term  may  be  allowed)  between  local  morbid 
conditions  and  symptomatic  phenomena,  is  important  to  be  con- 
sidered in  connection  with  diagnosis,  prognosis,  and  treatment.  It 
is  this  which  invests  the  physical  signs  of  disease,  whenever  they 
are  available,  with  much  of  their  great  practical  value.  Pericar- 
ditis being  associated,  in  the  great  majority  of  cases,  with  other 
affections,  its  own  manifestations  are,  to  a  greater  or  less  extent, 


298  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

intermingled  with,  and  obscured  by  tliose  of  the  latter.  This  fact, 
together  with  the  variations  just  alluded  to,  impairs  considerably 
the  general  application  of  a  descriptive  history  based  on  the  clini- 
cal study  of  the  comparatively  rare  cases  in  which  the  disease  is 
isolated,  and  its  symptomatic  phenomena  strongly  marked. 

The  division  of  the  career  of  the  disease  into  three  periods,  based 
on  facts  pertaining  to  its  morbid  anatomy,  is  to  be  borne  in  mind. 
The  symptoms  undergo  important  modifications  when  an  abundant 
accumulation  of  liquid  takes  place  in  the  pericardial  sac,  in  other 
words,  during  the  second  period;  and,  again,  after  absorption  of 
the  liquid,  or  during  the  third  period. 

In  treating  of  the  symptomatology  of  pericarditis,  the  symptoms 
which  relate  directly  to  the  heart  will  be  first  noticed,  and,  after- 
w^ard,  those  referable  to  different  anatomical  systems — the  circula- 
tory, respiratory,  nervous,  etc. 

Symptoms  referable  directly  to  the  heart. 

The  symptoms  which  relate  directly  to  the  heart,  are  pain,  palpi- 
tation and  tenderness. 

Pain  referred  to  the  prascordia,  is  a  prominent  symptom  in  some 
cases.  The  character  of  the  pain  is  burning  or  lancinating,  and  it 
is  accompanied  often  by  a  sense  of  constriction.  It  is  aggravated 
by  inspiration ;  and  the  inspiratory  acts  are  sometimes  shortened 
in  consequence,  the  number  of  respirations  per  minute  being  corre- 
spondingly multiplied.  The  pain  is  also  increased  by  movements 
of  the  body.  It  may  be  referred  to  the  region  of  the  heart  or  to 
the  epigastrium.  In  two  cases  under  my  observation,  it  was  at  first 
seated  on  the  right  side  of  the  sternum,  and  shortly  shifted  to  the 
praecordia.  It  may  extend  to  the  back,  to  the  left  shoulder,  and 
down  the  left  upper  extremity,  bearing  some  resemblance,  if  severe, 
to  the  pain  in  angina  pectoris.  The  character  of  the  pain,  and  the 
associated  circumstances  being  the  same  in  some  cases  as  in  pleu- 
risy, the  affection  is  liable  to  be  mistaken  for  the  latter.  This  not 
infrequently  happens.  Pleurisy,  as  has  been  seen,  is,  in  many 
cases,  associated  with  pericarditis,  and  the  pain  belonging  to  each 
affection  separately,  cannot,  under  these  circumstances,  be  readily 
disconnected.  The  pain,  also,  is  not  unlike  that  incident  to  pleuro- 
dynia and  intercostal  neuralgia,  and  these  affections  may  coexist 
with  pericarditis.  But  pain  is  by  no  means  invariably  a  prominent 
symptom  of  pericarditis.    In  the  majority  of  cases  it  is  either  mode- 


PAIN    IN    ACUTE    PEEICARDITIS.  299 

rate  or  slight  in  degree.  It  may  be  wanting.  In  a  case  recently 
observed  in  which  pericarditis  was  consecutive  to  pleurisy  of  the 
left  side,  with  large  effusion,  the  heart  being  removed  to  the  right 
of  the  sternum,  no  pain  was  experienced  in  the  organ  at  the  time 
of  the  attack,  or  subsequently.  In  another  instance,  the  pain  was 
slight,  and  referred  to  the  region  of  the  dorsal  vertebrae.  In  most 
of  the  cases  which  have  fallen  under  my  observation,  the  pain  has 
been  either  slight  or  moderate.  I  have  never  witnessed  excrucia- 
ting suffering  from  pain  in  connection  with  pericarditis,  but  in- 
stances have  been  reported.  This  symptom,  thus,  is  variable  in 
degree ;  it  is  not  reliable  as  a  constant  symptom,  and,  when  more 
or  less  marked,  is  not  distinctive. 

Upon  what  does  the  occurrence  of  pain  depend  ?  Bouillaud 
attributes  it,  in  all  cases,  to  coexisting  pleuritis.  But  it  may  un- 
doubtedly be  present,  and  prominent  as  a  symptom,  when  pleurisy 
does  not  coexist.  It  must  emanate  from  the  nerves  of  the  heart ; 
and,  although  it  is  difficult  to  explain  the  differences  in  the  amount 
of  pain  in  different  cases  which  appear  to  be  similar  as  regards  the 
intensity  of  the  inflammation,  and  to  account  for  the  absence  of 
pain  in  certain  instances,  it  is  to  be  considered  that  the  same  diffi- 
culty is  met  with  in  other  serous  inflammations,  for  example,  peri- 
tonitis. The  increase  of  pain  during  the  act  of  inspiration  is 
explained  by  the  friction  of  the  pericardial  surfaces  in  consequence 
of  the  depression  of  the  diaphragm,  and  by  the  pressure  upon  the 
heart,  of  the  lungs  in  the  process  of  inflation.  When  pain  is  present, 
it  belongs  especially  to  the  commencement  of  the  attack  and  the 
early  part  of  the  disease.  It  diminishes  or  disappears  when  the 
inflamed  surfaces  become  covered  with  lymph,  and  are  separated 
by  liquid  effusion.  At  this  stage  it  may  give  place  to  a  sense  of 
uneasiness  or  undefined  distress  referable  to  the  prsecordia,  not 
amounting  to  positive  pain. 

Tenderness  on  pressure  is  a  symptom  frequently  but  not  con- 
stantly present.  Like  pain,  when  present,  it  is  variable  in  degree, 
It  is  rarely  very  marked.  As  pointed  out  by  Hope,  tenderness 
may  sometimes  be  discovered  on  pressing  upon  the  epigastrium 
beneath  the  cartilages  of  the  ribs  in  a  direction  toward  the  heart, 
when  it  is  not  apparent  in  the  prascordia  directly  over  the  heart. 
In  order  to  constitute  a  symptom  of  pericarditis,  it  must  be  limited 
to  the  region  of  the  heart.  It  is  needless  to  say  that  when  pleurisy, 
affecting  the  left  side,  coexists,  the  tenderness  will  be  diffused,  more 
or  less,  over  the  whole  of  that  side.     In  acute  rheumatism,  pleuro- 


300  IXFLAMMATOEY   AFFECTIOXS    OF    THE    HEART. 

dynia  ma}'-  occur,  either  with  or  without  pericarditis,  and  diffused 
tenderness  will  then  be  present.  In  rheumatic  pericarditis,  I  have 
found  the  whole  of  the  left  side  exquisitely  sensitive  to  pressure, 
without  the  physical  evidence  of  pleuritis.  As  an  isolated  symp- 
tom, circumscribed  tenderness  is  of  little  value,  but,  taken  in  con- 
nection with  other  symptoms,  it  is  of  importance.  It  is  to  be  borne 
in  mind  that  the  absence  of  tenderness  is  not  positive  evidence 
against  the  existence  of  pericarditis. 

Tenderness  is  doubtless  due  to  an  abnormal  sensibility  developed 
in  the  inflamed  membrane.  Why  this  sensibility  is  present  in  some 
cases  and  not  in  others,  cannot  be  explained ;  but  the  same  is  true 
of  other  serous  inflammations.  In  peritonitis,  for  example,  the 
tenderness  is  generally  great ;  but  in  a  well-marked  case  at  this 
moment  under  observation,  this  symptom  is  wanting. 

Increased  action  of  the  heart  is  an  effect  of  pericardial  inflamma- 
tion during  the  early  part  of  the  disease.  The  contractions  are 
violent  and  sometimes  irregular.  The  patient  is  conscious  of  an 
unnatural  beating  of  the  organ.  This  constitutes  palpitation.  Like 
the  other  symptoms  referable  to  the  heart,  this  is  by  no  means  con- 
stant, and  it  possesses,  in  itself,  but  little  value  inasmuch  as  it  occurs 
in  connection  with  the  different  forms  of  organic  disease,  and,  also, 
as  a  purely  functional  disorder.  Its  importance  depends  on  its 
association  with  other  symptoms.  It  is  sometimes  strongly  marked. 
The  commencement  of  the  disease  may  be  characterized  by  tumul- 
tuous action  of  the  heart.  In  cases  of  acute  rheumatism,  this  should 
excite  strong  suspicion  of  pericarditis,  and  lead  to  a  careful  exami- 
nation for  more  positive  evidence  of  the  disease.  Palpitation 
belongs  to  the  first  stage  of  pericarditis.  It  is  incompatible  with 
much  liquid  effusion,  and  even  if  the  latter  does  not  occur,  a 
secondary  effect  of  the  inflammation  on  the  muscular  substance  of 
the  heart,  is  diminished  power  of  contraction,  or  incomplete  par- 
alysis. A  similar  effect  is  observed  in  cases  of  peritonitis,  as  shown 
by  enlargement  of  the  intestines,  from  the  pressure  of  their  gaseous 
contents. 

Symptoms  referable  to  the  circulation. 

The  pulse,  considered  alone,  in  this,  as  in  most  diseases,  does  not 
furnish  characters  which,  in  a  diagnostic  point  of  view,  are  highly 
distinctive;  but,  the  diagnosis  being  made,  it  gives  important  in- 
formation respecting  the  condition  of  the  heart.     At  the  onset  of 


THE    PULSE    IN"   ACUTE    PEKICARDITIS.  801 

the  disease,  it  corresponds  to  the  increased  muscular  action  of  the 
organ,  and  is  frequently  strong,  quick,  vibratory,  as  well  as  more 
or  less  frequent  and  sometimes  irregular.      In  proportion  as  the 
heart  is  weakened,  in  the  progress  of  the  disease,  it  becomes  en- 
feebled;  and  when  in  conjunction  with  a  certain  amount  of  par- 
alysis, the  movements  of  the  organ  are  mechanically  restrained  by 
the  pressure  of  liquid  effusion,  the  pulse  is  notably  small  and  weak, 
with  more  marked  disturbance  of  its  rhythm.     It  represents,  thus, 
the  effects  of  the  disease,  vital  and  mechanical,  on  the  circulation. 
Dr.  Stokes  thinks  that  the  effect  upon  the  heart's  movements  pro- 
duced by  the  pressure  of  liquid  in  the  pericardial  sac  is  overrated, 
and  he  cites,  in  support  of  this  opinion,  the  comparatively  small 
disturbance  of  the  circulation  caused  by  dislocation  of  the  heart  in 
cases  of  empyema.     But  the  condition  of  the  organ  in  the  two  cases 
is  by  no  means  the  same.     When  the  heart  is  removed  to  the  right 
of  the  sternum  by  the  pressure  of  a  large  accumulation  of  liquid  in 
the  left  pleural  sac,  the  freedom  of  its  movements  is  but  little 
restrained  in  comparison  with  the  effect  of  an  abundant  effusion 
within  the  pericardial  sac.     When  the  latter  is  distended  to  double 
or  treble  its  normal  capacity,  it  is  truly  surprising  that  the  cavities 
receive  sufficient  blood  for  the  circulation  to  be  carried  on.     The 
fact  that  the  circulation  is  not  arrested,  shows  the  force  with  which 
the  blood  is  returned  to  the  heart.     In  dwelling  upon  the  atony  or 
paralysis  arising  from  the  proximity  of  the  inflamed  membrane  to 
the  muscular  tissue.  Dr.  Stokes  seems  to  me  to  undervalue  the 
mechanical  effect  of  the  presence  of  liquid.     The  latter  effect  is  pro- 
portionate, other  things  being  equal,  not  so  much  to  the  amount  of 
liquid  effusion  as  to  the  rapidity  with  which  it  takes  place.     If  it 
accumulate  slowly,  the  dilatation  of  the  sac  goes  on  pari  passu ^  and 
the  heart,  speaking  metaphorically,  becomes  accustomed  to  the  pres- 
sure.    If  the  quantity,  on  the  other  hand,  become  rapidly  large,  the 
sac  does  not  readily  yield,  and  the  heart  sufiers  from   the  com- 
pression in  a  more  marked  degree.     Clinical  observation  sustains 
the  correctness  of  these  remarks.     The  pulse  may  be  greatly  en- 
feebled from  the  weakness  of  the  heart  induced  as  a  secondary 
result  of  the  inflammation,  irrespective  of  effusion.     But  the  pres- 
sure of  liquid,  especially  when  rapidly  efl'used,  afi'ects  the  pulse  to 
a  still  greater  extent.     A  weak  and  small  pulse  belongs  to  the  stage 
of  effusion,  and  may  be  considered  as  representing,  in  a  great  mea- 
sure, the  extent  to  which  the  heart  is  mechanically  restrained.     As 
regards  frequency  of  the  pulse,  Dr.  Walshe  remarks  that  it  "is 


302  INFLAMMATORY    AFFECTIONS    OF    THE    HEAET. 

subject  to  more  sudden  variations  from  the  influence  of  emotional 
excitement  and  effort  than  in  any  other  disease,  perhaps."  He  adds 
that  he  has  known  a  very  gentle  movement  of  the  trunk  raise  the 
pulse  from  80  or  90  to  130  or  140.  It  is  often  found  to  vary 
notably  on  different  days,  without  any  obvious  cause. 

During  the  progress  of  pericarditis,  then,  as  a  rule,  the  pulse  is 
at  first  more  or  less  increased  in  frequency,  and  also  in  force  and 
quickness;  and,  afterwards,  from  the  combined  effects  of  diminished 
muscular  power  and  the  pressure  of  liquid  effusion,  it  is  irregular, 
weak  and  small,  the  frequency  being  generally  still  more  increased. 
But  to  this  rule  there  are  exceptions.  The  frequency  during  the 
first  stage  is,  in  some  cases,  not  greater  than  in  health.  Dr.  Graves, 
indeed,  states  that  he  has  observed  it  to  be  less  frequent  than  in 
health.  It  may  continue  regular  during  this  stage,  and  present  no 
marked  deviation  from  its  normal  characters.  During  the  second 
stage,  the  effect  of  even  a  large  accumulation  of  liquid  is  sometimes 
not  very  marked.  It  may  retain  considerable  force  and  volume 
when  the  extinction  of  prascordial  impulse  and  other  physical  signs 
show  distension  of  the  pericardial  sac. 

In  cases  of  rheumatic  pericarditis,  the  pulse  is  more  or  less 
accelerated  prior  to  the  development  of  the  heart  affection.  The 
influence  of  the  latter,  therefore,  cannot  be  estimated  with  precision. 
A  sudden  change  in  frequency,  or  other  characters,  during  the 
course  of  acute  rheumatism,  occurring  when  no  joints  are  newly 
attacked,  and  irrespective  of  any  obvious  cause,  should  lead  the 
practitioner  always  to  direct  his  attention  to  the  symptoms  and 
signs  of  cardiac  disease. 

The  obstruction  to  the  circulation  incident  to  prolonged  accumu- 
lation of  liquid  in  the  sac  may  be  sufficient  to  give  rise  to  oedema 
of  the  lower  extremities  and  face.  In  general,  however,  oedema  in- 
volves coexisting  disease  of  kidney,  or  organic  lesions  of  the  heart. 

Lividity  of  the  lips,  face,  etc.,  may  be  due  alone  to  the  pressure 
of  liquid  and  weakness  of  the  heart.  As  a  symptom  of  pericarditis, 
exclusive  of  other  affections,  it  belongs  to  the  second  stage  of  the 
disease,  and  denotes  an  alarming  degree  of  obstruction.  The  pulse 
will  be  found  to  be,  at  the  same  time,  extremely  feeble  and  irregu- 
lar. The  lividity,  under  these  circumstances,  depends  on  congestion 
of  the  venous  radicles,  arising  from  inability  of  the  heart  to  receive 
the  blood  returned  to  it  by  the  systemic  veins.  But  this  symptom 
generally  involves  an  affection  of  the  pulmonary  system,  such  as 
pleuritis  or  pneumonitis,  existing  in  combination  with  the  pericar- 


COUGH,    DYSPNCEA,    ETC.,    IN    ACUTE    PEKICARDITIS.      303 

ditis.  The  impaired  ability  of  the  lungs  to  aerate  the  blood  is  then 
associated  with  venous  congestion  in  the  production  of  lividity.  It 
is  unnecessary  to  add  that  lividity  is  a  symptom  incident  to  a  va- 
riety of  cardiac  and  pulmonary  affections,  and  does  not  therefore 
possess  any  intrinsic  significance  as  diagnostic  of  pericarditis.  It 
is  not,  in  fact,  always  present  in  fatal  cases  of  the  latter  disease, 
even  when  characterized  by  great  liquid  effusion.  These  remarks 
are  equally  applicable  to  the  symptom  last  noticed,  viz.,  oedema. 

Symptoms  referable  to  the  respiratory  system. 

In  cases  of  pericarditis  disconnected  from  any  affection  of  the 
lungs,  the  respirations  are  sometimes  accelerated  in  consequence  of 
the  inspiratory  acts  being  shortened  by  prsecordial  pain.     I  have 
observed  marked  dilatation  of  the  alee  nasi  under  these  circum- 
stances.    Cough,  dry,  hacking,  or  spasmodic,  is  common,  and  does 
not  denote,  necessarily,  coexisting  pulmonary  disease.     Dyspnoea 
may  be  an  urgent  symptom,  dependent  generally  on  congestion  of 
the  lungs  incident  to  compression  of  the  heart  by  liquid  effusion. 
These  symptoms,  however,  are  extremely  variable  and  inconstant, 
as  are  all  the  symptomatic  events  belonging  to  the  clinical  history 
of  pericarditis.     The  respiration  may  be  unaffected,  or  accelerated 
only  in  proportion  to  the  febrile  movement.    Cough  is  not  uniformly 
present.     Dyspnoea  may  be  wanting  even  when  the  pericardial  sac 
is  largely  distended.     Moreover,  each  of  these  sj^mptoms  occurs  in 
a  variety  of  pathological  relations,  and  is  not,  therefore,  distinctive 
of  pericarditis.     They  are  often  dependent,  to  a  greater  or  less  ex- 
tent, on  coexisting  pleurisy  or  pneumonia.     When  these  affections 
are  excluded,  dyspnoea  denotes,  as  a  rule,  obstruction  to  the  circu- 
lation caused  by  weakness  of  the  heart  or  mechanical  compression, 
or  both  combined.     As  thus  produced,  it  may  exist  in  a  degree  to 
constitute  orthopnoea.     It  belongs,  in  general,  to  the  second  stage 
of  the  disease,  and  is  associated  with  frequency  and  feebleness  of 
the  pulse,  and  perhaps  with  lividity  of  the  prolabia  and  face.     Un- 
der these  circumstances,  it  denotes  imminent  danger.     Cases,  how- 
ever, have  been  observed  in  which  dyspnoea,  and  even  orthopnoea, 
existed  at  the  commencement  of  the  disease,  prior  to  effusion,  and 
when  it  was  not  attributable  to  any  coexisting  pulmonary  affection. 
In  some  instances,  as  suggested  by  Dr.  Sibson,  the  distended  peri- 
cardial sac  may  add  to  the  dyspnoea  by  pressing  on  the  trachea  at 
its  bifurcation.     The  augmented  space  w^hich  the  pericardial  sac 


304         INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

occupies  when  largely  distended  also  contributes  to  the  production 
of  dyspnoea. 

The  voice  has  been  observed  to  be  remarkably  weak,  the  patient 
being  unable  to  speak  in  feeble  tones  without  considerable  effort. 
Dr.  Walshe,  who  has  noticed  this  symptom,  states  that  it  seems  to 
be  mainly  connected  with  copiousness  of  effusion. 

Sym2ytoms  referable  to  the  digestive  system. 

Certain  cases  of  pericarditis  are  characterized  by  prominent 
sjmiptoms  referable  to  the  digestive  system,  but,  occurring  only 
occasionally,  they  are  incidentally  connected  with  the  disease,  and 
can  hardly  be  considered  as  forming  a  part  of  its  clinical  history. 
Thus,  vomiting  is  sometimes  present  and  persisting  in  a  marked 
degree.  Dr.  Copland  has  remarked  that,  under  these  circumstances, 
there  is  some  liability  to  mistake  the  disease  for  gastritis,  the  rapid, 
weak,  irregular  pulse,  etc.,  being  attributed  to  a  tendency  of  the 
latter  affection  to  an  unfavorable  termination.  Dysphagia  is  an- 
other sj^mptom  belonging  in  this  category.  Its  occasional  occur- 
rence in  cases  of  pericarditis  was  noticed  by  an  Italian  author, 
Testa,  who  published  a  work  on  diseases  of  the  heart  in  1811.' 
Dr.  Stokes  and  Dr.  Walshe  have  observed  it  in  several  cases.  It 
has  not  been  ascertained  to  depend  on  any  appreciable  alteration  in 
the  pharynx  or  the  adjoining  parts,  and  is  therefore  to  be  regarded 
as  either  a  spasmodic  affection,  or  a  mechanical  effect  of  pressure  of 
the  distended  pericardial  sac  upon  the  oesophagus. 

These  are  the  only  symptoms  to  be  mentioned  under  this  head. 
Loss  of  appetite,  thirst,  constipation,  etc.,  are  incident  to  pericar- 
ditis as  well  as  to  acute  inflammation  affecting  any  important  organ, 
and  accompanied  by  febrile  movement. 

Symptoms  referable  to  the  countenance,  position,  etc. 

An  expression  of  anxiety  or  apprehension  is  frequently  a  marked 
symptom,  as  it  is  in  cases  of  merely  functional  disorder  of  the  heart. 
In  severe  cases,  near  the  fatal  termination,  the  risus  sardonicus  has 
been  observed.  Lividity  and  oedema  are  occasional  symptoms 
which  have  been  already  mentioned. 

The  position  assumed  by  the  patient  is  generally  on  the  back ; 

'  Vide  Stokes  ou  Diseases  of  the  Heart  and  Aorta,  Am.  ed.,  p.  69. 


MENTAL    CONDITION    IN   ACUTE    PERICARDITIS.  305 

or  he  takes  a  diagonal  position  between  tliat  on  the  back  and  on 
the  side.  He  rarely  lies  on  the  left  side,  the  liver  in  this  position 
pressing  upon  the  heart,  and  thus  giving  rise  to  discomfort  or 
adding  to  the  distress.  In  some  cases  a  position  on  the  right  side 
is  not  uncomfortable.  If  pleurisy  or  pneumonia  coexist,  the  decu- 
bitus will,  of  course,  be  in  a  measure  determined  by  these  affections. 
Generally,  but  not  invariably,  the  patient  desires  to  have  the  head 
and  shoulders  raised. 

All  observers  have  noticed  this  point  relating  to  position,  viz., 
whatever  may  be  that  selected  by  the  patient,  he  is  reluctant  to 
change  it;  ^,  e.,  he  desires,  as  much  as  possible,  to  maintain  the 
same  position.  This  is  accounted  for  by  the  fact  that  movements 
of  the  body  increase  distress,  and,  by  exciting  the  heart,  give  rise 
to  a  sense  of  syncope,  especially  when  the  pericardial  sac  is  dis- 
tended with  liquid.  Fatal  syncope  may  be  induced  by  a  change 
of  position.  I  have  known  death  to  occur  suddenl}'-,  when  a  fatal 
termination  was  not  expected,  apparently  being  caused  by  the  pa- 
tient rising  from  bed  and  going  to  stool. 

When  the  amount  of  liquid  effusion  is  large,  a  recumbent  posi- 
tion on  the  back  may  still  be  preferred ;  but  instances  have  been 
observed  in  which  patients  have  experienced  relief  from  lying  on 
the  face.  If  dyspnoea  be  urgent,  a  sitting  posture  may  be  alone 
tolerable,  the  dyspnoea  then  constituting  orthopnoea.  Under  these 
circumstances,  restless  movements  of  the  arms  are  common,  the 
body  remaining  comparatively  immovable. 

Symptoms  referable  to  the  nervous  system. 

Mental  aberration,  moderate  or  slight,  and  transient,  is  not  un- 
common in  cases  of  pericarditis.  I  have  known  it  to  occur  at  the 
commencement  of  the  disease,  and  soon  disappear,  the  patient  after- 
ward preserving  the  faculties  of  the  mind  to  the  close  of  life.  It  is 
oftener  observed  at  a  later  period  in  fatal  or  severe  cases.  It  is  not, 
however,  an  element  of  the  disease.  In  many,  perhaps  in  the  ma- 
jority of  cases,  it  is  wanting.  But  in  certain  cases  of  pericarditis, 
cerebral  symptoms  are  developed  which  are  highly  important  in 
themselves,  and  also  because  they  serve  to  mask  the  local  symp- 
toms of  cardiac  disease.  The  cerebral  symptoms  now  referred  to, 
resemble  those  which  characterize  different  affections  of  the  nervous 
system.  Inflammation  of  the  meninges  of  the  brain,  mania,  de- 
mentia, coma,  epilepsy,  tetanus,  and  chorea  have  been  simulated  in 
20 


306  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

cases  of  pericarditis,  the  latter  disease  being  generally  overlooked 
before  death,  and  examination  post-mortem  revealing  no  appre- 
ciable lesions  of  the  brain  or  spinal  cord  adequate  to  explain  the 
phenomena  observed  during  life.  The  phenomena  in  these  remark- 
able, and,  as  they  have  been  justlj''  called,  fearful,  cases  must  needs 
be  diversified  in  order  to  give  rise  to  a  resemblance  to  each  of  the 
several  affections  just  named ;  yet  there  are  certain  features  which 
are  somewhat  distinctive.  This  subject  has  been  considered  more 
fully  by  Dr.  Burrows  than  by  any  other  author  wdthin  my  know- 
ledge.' Dr.  Burrows  gives  a  synopsis  of  all  the  cases  that  he  was 
able  to  gather  from  various  sources.  It  is  remarkable  that  the 
subject  is  merely  alluded  to  in  works  devoted  specially  to  diseases 
of  the  heart.  Without  detailing  the  cases  which  have  been  reported, 
I  shall  refer  to  them  sufficiently  to  present  a  sketch  of  the  varied 
symptoms  which  they  embrace;  and  I  shall  add  a  brief  account  of 
three  striking  cases  which  have  fallen  under  my  own  observation. 
So  much,  the  importance  of  the  subject  seems  to  me  to  demand. 

The  first  recorded  case,  according  to  Dr.  Burrows,  was  reported 
by  Dr.  Stanley  in  1817.  The  next  case  was  communicated  by  Dr. 
Abercrombie  in  1821.  Dr.  Latham  reported  a  case  in  1828;  and 
he  states  that  "when  he  first  related  the  particulars  of  his  case  to 
several  medical  friends,  they  looked  incredulous,  or  rather  con- 
temptuous of  the  man  who  would  mistake  an  inflammation  of  the 
pericardium  for  an  inflammation  of  the  brain."  In  each  of  these 
cases  the  patient  was  supposed  to  labor  under  a  cerebral  affection, 
to  which  the  treatment  was  directed,  and  the  existence  of  cardiac 
disease  was  not  suspected  prior  to  the  autopsical  examination.  The 
brain  presented  no  evidence  of  disease  bej'ond  a  certain  amount  of 
congestion.  Other  cases  were  subsequently  reported  by  Andral, 
Bouillaud,  Copland,  Mcintosh,  McLeod,  Hawkins,  Bright,  Watson, 
and  others.  Dr.  Burrows  states  that  not  less  than  six  cases  have 
come  under  his  own  observation.  Of  16  recorded  cases  cited  by 
the  author  last  named,  11  proved  ftUal,  and  only  5  recovered.  Of 
the  11  fatal  cases,  in  2  only  was  an  affection  of  the  heart  detected 
during  life;  in  1  cardiac  disease  was  suspected,  but  in  the  remaining 
8  cases  there  was  no  suspicion  of  an  acute  affection  of  the  heart 
until  it  was  revealed  by  an  examination  after  death.    Of  the  5  suc- 

'  On  Disorders  of  the  Cerebral  Circulation,  and  on  the  Connection  between  Affec- 
tions of  the  Brain  and  Diseases  of  the  Heart.  By  George  Burrows,  M.  D.,  etc. 
Am.  edition,  1848. 


CEEEBEAL    SYMPTOMS    IN    ACUTE    PERICARDITIS.        307 

cessful  cases,  in  4  the  diagnosis  of  cardiac  disease  was  satisfactorily 
established.  A  rational  inference  from  these  facts  is,  that  when  the 
existence  of  cardiac  disease  is  ascertained,  the  cases  are  usually 
amenable  to  treatment;  but,  on  the  other  hand,  when  the  cardiac 
affection  is  overlooked,  a  fatal  result  usually  occurs. 

In  the  sixteen  cases  detailed  in  Dr.  Burrows'  work,  were  mani- 
fested, delirium,  convulsions,  agitation  of  the  limbs  resembling 
chorea,  a  state  of  dementia,  a  species  of  coma,  seizures  resembling 
apoplexy,  and  tetanic  spasms.  The  delirium  was  characterized 
by  taciturnity,  and  maniacal  excitement  under  the  influence  of 
delusions  involving  the  idea  of  having  committed  some  crime. 
Convulsions  occurred  in  paroxysms,  and  the  choreic  form  was 
accompanied  by  rolling  of  the  eyes  and  head,  as  well  as  violent 
agitation  of  the  limbs.  The  coma  was  characterized  by  the  eyelids 
remaining  open,  and  the  eyes  fixed.  In  the  apoplectiform  seizures, 
the  eyeballs  were  turned  upward  and  the  limbs  paralj^zed.  In 
several  instances,  violent  tonic  spasms  occurred,  resembling  tetanus. 
In  the  fatal  cases,  death  was  generally  preceded  by  ordinary  coma. 

The  first  of  the  cases  which  have  fallen  under  my  observation, 
occurred  in  1849,  and  was  reported  by  me,  February,  1850.^  The 
patient  was  admitted  into  the  hospital  in  a  state  of  active  delirium, 
and  nothing  was  ascertained  respecting  the  previous  history.  On  the 
following  day  he  was  tranquil,  and,  when  spoken  to,  made  no  reply, 
shaking  his  head.  The  eyes  had  a  wild,  staring  expression.  He 
could  not  be  made  to  protrude  the  tongue.  Pulse  small,  feeble, 
and  not  accelerated.  Active  delirium  occurred  at  intervals,  during 
which  he  shouted  and  cried,  as  if  from  apprehension  of  danger. 
At  other  times  he  la3^  with  his  eyes  open  and  fixed  in  a  particular 
direction,  taking  no  notice  of  persons  and  things  around  him.  On 
several  occasidns  he  answered  questions,  and  he  then  gave  evidence 
of  the  delusion  that  he  had  committed  some  crime.  Once,  when 
asked  how  he  was,  he  replied,  "  Guilty."  At  another  time  he  had 
an  impression  that  he  Avas  confined  in  jail,  and  subsequently  he 
asked  why  he  had  not  been  hung,  etc.  On  the  fourteenth  day 
after  his  admission,  he  complained,  for  the  first  time,  of  pain  in  the 
chest,  and,  on  physical  examination,  the  signs  of  pleuro-pneumonia 
were  discovered.  There  were  no  cough  and  expectoration.  Death 
occurred  on  the  seventeenth  day.  Delirium  with  hilarity  occurred 
on  the  last  day,  and  he  became  comatose  for  several  hours  before 

'  Buffalo  Medical  Journal,  vol.  v.  p.  505. 


308  INFLAMMATORY    AFFECTIOXS    OF    THE    HEART. 

death.  On  examination  post-mortem,  the  left  lung  was  in  the 
second  stage  of  inflammation,  and  the  pleural  sac  contained  about 
twelve  ounces  of  turbid  serum.  The  surface  of  the  heart  was 
covered  with  recently  exuded  lymph.  The  endocardial  membrane 
was  healthy  and  the  valves  sound.  The  brain  presented  no  other 
evidence  of  disease  than  a  considerable  amount  of  congestion,  and 
slight  opacity  of  the  arachnoid  over  the  superior  surface  of  the 
cerebrum. 

The  existence  of  pericarditis  was  not  suspected,  in  this  case, 
prior  to  the  autopsy.  Up  to  the  fourteenth  day,  the  afiectipn  Avas 
supposed  to  be  exclusively  cerebral,  no  symptoms  pointing  to  the 
chest  as  the  seat  of  the  disease.  Physical  exploration  was  neglected 
until  the  date  just  stated,  when  pneumonia  was  ascertained. 

The  second  case  came  under  observation  in  the  hospital  at  Buffalo 
in  iy51,  and  was  reported  by  me  in  January,  1854.^  At  my  morn- 
ing visit,  I  found  that  on  the  previous  evening  a  patient  had  been 
admitted  greatly  prostrated  and  delirious.  Nothing  was  obtained 
relative  to  the  previous  history.  The  patient  had  not  spoken  since 
his  admission.  He  lay  with  his  eyes  open,  fixed,  most  of  the  time, 
in  one  direction,  taking  no  notice,  and  making  no  reply  to  ques- 
tions. A  disagreeable  peculiarity  in  this  case  was,  that  the  patient 
frequently  ejected  saliva  with  force,  and  without  any  regard  to  its 
destination.  His  bed  and  the  floor  were  bespattered  with  spittle. 
Persons  in  proximity  to  him  were  liable  to  receive  it  on  their  per- 
sons, not  from  design,  but  because  it  was  scattered  at  random,  the 
patient  not  changing  his  position  and  lying  on  his  back.  Under 
these  circumstances,  an  examination  of  the  case  was  deferred,  and 
at  my  next  visit  I  found  that  the  patient  had  died.  At  the  time  I 
was  observing  the  patient,  the  idea  of  pericarditis  did  not  occur  to 
me,  but  in  thinking  of  the  case  afterwards,  a  resemblance  in  the 
character  of  the  delirium  to  that  in  the  preceding  case,  led  me  to 
suspect  this  disease ;  so  that,  before  the  autopsy  was  made,  I  ven- 
tured to  predict  that  it  would  be  discovered.  My  prediction  proved 
true.  The  pericardium  was  universally  adherent  by  recent  tender 
adhesions.     Pulmonary  disease  did  not  coexist  in  this  case. 

The  foregoing  cases  ended  fatally.  The  third  case  came  under 
observation  in  the  Louisville  Marine  Hospital,  October,  1853,  and 
terminated  in  recovery.  This  case  was  reported  in  connection 
with  the  preceding  case.     When  admitted,  the  mind  of  the  patient 

'  Buffalo  Medical  Journal,  vol.  ix.  p.  449. 


CEREBRAL    SYMPTOMS    IN    ACUTE    PERICARDITIS.       309 

was  too  dull  to  give  any  connected  account  of  past  or  present 
symptoms.  On  the  day  following  he  was  delirious,  frequently 
getting  out  of  bed,  and  seemed  bewildered.  The  next  day  he  was 
unconscious.  He  lay  upon  the  back,  taking  no  notice  of  persons 
and  things  around  him.  He  had  lost  one  eye  ;  the  other  remained 
open,  and  the  pupil  was  dilated.  He  was  taciturn,  and  could  not  be 
roused  to  reply  to  questions;  he  urinated  in  bed;  the  saliva  escaped 
from  the  mouth,  and  he  did  not  swallow  when  drink  was  intro- 
duced. The  physical  signs,  exclusive  of  friction-.sounds,  were 
sufficient  to  establish  the  existence  of  pericarditis  with  moderate 
effusion. 

Convalescence  was  established  a  fortnight  after  his  admission. 
For  three  days  he  took  neither  drink  nor  nourishment,  making  no 
effort  to  swallow,  and  sometimes  resisting  their  introduction  by 
forcibly  closing  the  teeth.  At  times  during  the  three  first  days  he 
was  exceedingly  restless,  throwing  himself  from  the  bed,  so  that  it 
became  necessary  to  transfer  him  to  the  floor.  The  pulse  was  80, 
and  the  respirations  28.  On  the  fourth  day,  in  the  morning,  there 
was  marked  improvement.  The  patient  took  food  and  drink,  and 
appeared  to  notice  objects  around  him.  This  peculiarity  was 
observed,  viz.,  he  directed  his  vision  to  some  point,  now  a  portion 
of  the  pillow  and  now  his  hand,  protruded  his  tongue  towards  it, 
and  then  slowly  grasped  it  with  his  lips  and  teeth.  This  he 
repeated  frequently.  In  the  course  of  the  day  he  again  became 
restless,  throwing  himself  about,  getting  up,  calling  names  of  dif- 
ferent persons.  The  day  following,  his  expression  was  idiotic. 
His  eye  was  open,  and  he  looked  about  with  a  vacant  stare.  He 
resisted  phj^sical  exploration.  Twice  he  said  while  the  record  of 
symptoms  was  being  made,  "I  beg  pardon."  These  words  were 
uttered  spontaneously,  with  slowness  and  hesitancy.  He  did  not 
reply  to  questions,  and  was  taciturn  the  greater  part  of  the  time. 
On  the  sixth  day  he  had  three  attacks  of  convulsions  an  hour  in 
duration.  These  recurred  on  the  day  following.  In  the  intervals 
he  frequently  got  out  of  bed  and  endeavored  to  break  the  walls  of 
the  room,  as  if  to  escape  from  persons  threatening  violence.  It 
was  necessary  to  apply  a  restraining  jacket.  On  the  eighth  day  he 
lay  night  and  day  rolling  about  the  floor  and  shouting  incoherent 
words.  On  the  tenth  day  he  continued  wakeful,  shouting,  with 
occasional  manifestations  of  hilarity.  In  the  course  of  this  day  he 
slept  quietly  for  several  hours,  took  food  and  drink  readily,  pro- 
truded the  tongue,  and  replied  to  questions.     From  this  time  he 


810  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

was  rational,  and,  on  being  questioned,  said  that  he  had  pain  in 
the  left  breast  above  the  nipple,  lancinating,  and  increased  by  deep 
inspiration.  He  had  no  recollection  of  the  events  of  the  previous 
fortnight.  He  stated  that  he  was  ill  for  two  days  before  coming  to 
the  hospital,  and  that  he  suffered  chiefly  from  pain  in  the  left 
breast.     He  convalesced  from  this  date. 

The  physical  signs  on  which  the  diagnosis  was  based  in  this  case, 
were  flatness  on  percussion  over  an  'increased,  pyramidal  space  in 
the  prajcordia ;  elevation  of  the  point  of  apex  impulse  and  flatness 
below  this  point ;  irregularity  and  feebleness  of  the  heart's  contrac- 
tions; diminution  of  the  area  of  prtecordial  dulness  at  the  time  of 
convalescence,  and  retraction  of  the  intercostal  spaces  with  the 
heart's  action.  Friction-sounds  were  not  discovered,  but  the  early 
application  of  a  blister  over  the  prascordia  interfered  somewhat  with 
auscultatory  exploration.  In  connection  with  the  physical  signs 
denoting  pericarditis,  pain  referred  to  the  pra^cordia  was  a  pro- 
minent symptom  before  the  patient  entered  the  hospital,  and  was 
felt  after  his  consciousness  returned,  together  with  tenderness  in 
the  same  region,  evidently  not  dependent  on  the  blister.  Acute 
pulmonary  disease  was  excluded  by  the  absence  of  physical  signs, 
as  well  as  symptoms,  pertaining  to  the  lungs. 

It  is  worthy  of  remark  that  in  the  three  cases  of  pericarditis 
associated  with  cerebral  disorder,  of  which  an  account  has  just  been 
given,  the  disease  in  each  was  not  developed  during  the  course  of 
rheumatism.  Of  the  sixteen  cases  analyzed  by  Dr.  Burrows,  in 
seven  no  rheumatic  affection  could  be  discovered.  In  the  third 
case  the  pericarditis  seemed  to  be  purely  idiopathic,  and  in  the  two 
other  cases  no  antecedent  affection  was  ascertained. 

Although  the  manifestations  of  cerebral  disorder  incident  to 
pericarditis  are  so  varied,  there  are  certain  points  of  resemblance 
in  the  different  cases,  and,  on  the  other  hand,  dissimilarity  in  certain 
respects  from  disorder  occurring  in  other  pathological  relations. 
The  variety  of  manifestations  occurring  in  the  same  case,  is  some- 
what distinctive.  Different  forms  of  delirium,  coma,  convulsions, 
etc.,  are  developed  successively  during  the  progress  of  the  disease. 
The  characters  pertaining  to  the  delirium  are  peculiar;  the  patient 
lying  in  a  species  of  coma  vigil,  the  eyes  open  and  fixed  in  one 
direction,  not  replying  to  questions,  and  incapable  of  being  roused; 
this  state  followed  by  maniacal  excitement,  the  patient  shouting 
and  apparently  laboring  under  the  fear  of  harm,  with  occasional 
ebullitions  of  hilaritj'-.    A  fixed  delusion  of  having  committed  some 


CEREBRAL    SYMPTOMS    IN    ACUTE    PERICARDITIS.       311 

crime,  appears  to  be  a  distinguishing  feature.  Meningeal  inflam- 
mation does  not  give  rise  to  this  sort  of  delirium.  Moreover,  the 
acute  pain  in  the  head,  throbbing  of  the  carotids,  injection  of  the 
eyes  and  face,  which  belong  to  the  symptomatology  of  acute  menin- 
gitis, are  wanting.  The  delirium  offers  but  a  faint  resemblance  to 
that  of  delirium  tremens,  and  to  that  which  is  distinguished  from 
the  latter  as  delirium  ebriosum.  It  has  no  resemblance  to  the  quiet, 
muttering  delirium  of  continued  fever,  nor  the  active  delirium 
which  sometimes  occurs  in  the  course  of  febrile  diseases.  These 
points,  if  not  diagnostic,  should,  at  all  events,  excite  strong  suspicion 
of  the  existence  of  pericarditis  in  the  absence  of  any  symptoms 
pointing  directly  to  the  heart  as  the  seat  of  disease.  The  diagnosis 
in  such  cases  must  rest  on  the  presence  or  absence  of  physical  signs 
denoting  inflammation  of  the  pericardium. 

The  symptoms  referable  to  the  nervous  system  which  have  been 
considered,  are,  happily,  infrequent.  But  instances  of  their  asso- 
ciation with  pericarditis  are  sufficiently  numerous  to  show  some 
pathological  connection  between  the  latter  disease  and  the  nervous 
disorder.  The  complication  is  not  due  merely  to  coincidence.  The 
instances,  in  fact,  it  is  probable,  are  more  numerous  than  would  be 
inferred  from  the  number  which  have  been  reported.  As  remarked 
by  Dr.  Burrows,  how  many  have  occurred  in  the  practice  of  phy- 
sicians who  have  been  less  candid  than  Drs.  Abercrombie,  Latham, 
and  others,  in  recording  their  mistakes,  and  how  great  a  number 
must  have  happened  in  the  practice  of  those  who  were  unable,  or 
took  no  pains  to  distinguish  these  deceptive  cases,  it  is  impossible 
to  say.  It  is,  however,  but  fair  to  add,  that  some  observers  of  large 
experience,  who  have  given  special  attention  to  diseases  of  the 
heart,  have  not  met  with  examples.  Dr.  Hope,  at  the  time  of  the 
publicjition  of  the  second  edition  of  his  work,  had  not  observed  an 
instance,  and  Dr.  Stokes,  in  his  recent  work,  alludes  to  the  subject 
in  terms  which  imply  that  an  instance  has  not  fallen  under  his 
observation.  The  author  last  named  considers  the  connection  be- 
tween the  nervous  disorder  and  pericarditis  as  doubtful. 

Of  the  nature  of  the  pathological  connection  assumed  to  exist 
between  the  nervous  symptoms  and  pericarditis,  but  little  is  to  be 
said.  The  former  are  not  dependent  on  any  appreciable  morbid 
conditions  of  the  brain  or  spinal  cord.  They  are,  therefore,  with 
our  present  knowledge,  to  be  regarded  as  fanctional.  They  have 
been  attributed  to  disordered  circulation,  an  altered  state  of  the 
blood,  and  nervous  irritation  transmitted  through  the  phrenic  and 


312  INFLAMMATORY   AFFECTIONS    OF    THE    HEART, 

pneumogastric  nerves.  Perhaps  the  most  rational  view  is,  that  they 
proceed  from  the  same  general  conditions  which  give  rise  to  the 
associated  pericarditis ;  in  other  words,  that  the  connection  is  simply 
one  of  a  common  causation. 

In  addition  to  the  symptoms  which  have  been  considered,  there 
are  none  of  importance,  referable  to  the  nervous  system,  remaining 
to  be  noticed.  Pain  seated  in  or  near  the  prtecordia,  is  included 
among  the  symptoms  relating  directly  to  the  heart.  Sleep  is  often 
more  or  less  impaired  by  pain  or  dyspnoea.  As  regards  the  state 
of  the  mind,  anxiety,  apprehension,  and  mental  depression  belong 
to  the  history  of  the  disease,  and  are  frequently  prominent  symp- 
toms. 

The  genito-urinary  system  offers  no  symptoms  which  have  special 
relations  with  pericarditis.  Albuminuria  coexists  in  a  pretty  large 
proportion  of  cases,  and  is  an  important  symptom  of  a  morbid  con- 
dition of  the  kidneys,  antecedent  to  the  pericarditis,  and  upon  which 
the  development  of  the  latter  depends.  Under  these  circumstances, 
it  is  not  properly  a  symptom  of  the  cardiac  disease. 


Physical  Signs  of  Acute  Pericarditis. 

In  treating  of  the  symptoms  of  acute  pericarditis,  the  absence  of 
distinctive  characters  derived  from  this  portion  of  the  clinical  his- 
tory of  the  disease,  has  been  apparent.  The  deficiency,  as  regards 
diagnostic  points,  in  the  symptomatic  events  which  have  been  con- 
sidered, enhances  the  importance  of  the  physical  signs.  In  fact,  it 
is  mainly  by  means  of  the  latter  that  the  disease  may  be  now 
generally  recognized  with  a  degree  of  positiveness  which  clinical 
observers,  but  a  few  years  ago,  regarded  as  unattainable.  Of  the 
several  methods  of  exploration,  all,  save  succussion,  furnish  signs 
of  more  or  less  value.  I  shall  consider  the  signs  obtained  by  per- 
cussion, auscultation,  palpation,  inspection,  and  mensuration,  re- 
spectively, under  separate  heads,  in  the  order  in  which  these  different 
methods  are  now  enumerated. 

Signs  furnished  by  jxrcussion. 

The  signs  furnished  by  percussion  in  pericarditis,  are  due  to  the 
accumulation  of  liquid  effusion.  The  value  of  this  method  of 
exploration  consists  in  the  information  which  it  affords  as  regards 


PERCUSSION    IN"   ACUTE    PERICARDITIS.  313 

the  presence  or  absence  of  liquid,  the  amount  of  distension  of  the 
pericardial  sac,  the  variations  in  the  quantity  of  liquid  during  the 
progress  of  the  disease,  and  its  final  disappearance. 

Accumulation  of  liquid  within  the  pericardial  sac  increases  the 
area  and  the  degree  of  prascordial  dulness,  and  renders  the  sense  of 
resistance  in  practising  percussion  greater  than  in  health.  Effects 
similar  to  these  are  produced  by  enlargement  of  the  heart.  The 
practical  inquiry,  therefore,  arises,  what  circumstances  distinguish 
the  increased  extent  and  amount  of  dulness  incident  to  the  presence 
of  liquid,  from  the  same  effects  as  produced  by  cardiac  enlarge- 
ment ? 

The  pericardium  is  a  pyriform  sac,  the  lower  extremity  forming 
the  base.  It  extends  upward  above  the  base  of  the  heart,  rising  as 
high  as  the  cartilage  of  the  second,  and  sometimes  of  the  first  rib. 
Unaffected  by  disease,  it  is  capable  of  holding,  as  determined  by 
Dr.  Sibson's  experiments  already  referred  to,  from  15  to  20  ounces 
of  liquid.  The  effusion  in  cases  of  acute  pericarditis  rarely  much 
exceeds  this  amount,  although  the  quantity  is  vastly  greater  in 
some  cases  of  the  chronic  form  of  the  disease.  The  area  of  dulness, 
when  the  sac  is  distended  with  liquid  effusion,  corresponds,  not 
only  to  the  increased  size,  but  to  the  form  and  situation  of  the  sac. 
In  acute  pericarditis  the  sac  does  not  undergo  any  marked  altera-/ 
tion  in  shape  or  dimensions.  It  forms,  when  enlarged  to  its  full 
capacity,  a  pyriform  tumor  extending  from  the  junction  of  the 
cartilage  of  the  second  or  first  rib  with  the  sternum,  on  the  left 
side,  downward  to  the  sixth  rib  or  intercostal  space.  Laterally,  in 
proportion  to  the  distension,  it  pushes  aside  the  lungs,  increasing 
the  space  caused  b}''  the  divergence  of  the  right  and  left  lung, 
called  the  superficial  cardiac  region.  If  the  liquid  be  not  sufficient 
to  distend  the  sac,  it  gravitates  to  the  lower  part,  and  the  dilatation 
advances  from  the  base  upward  in  proportion  as  the  accumulation 
goes  on.  After  a  certain  amount  of  accumulation  has  taken  place, 
the  heart  is  raised  upward,  and  the  base  of  the  sac  somewhat 
depressed,  so  that  the  apex  of  the  organ  is  situated  at  a  distance 
from  the  bottom  of  the  sac,  the  space  below  the  apex  being,  of 
course,  occupied  by  liquid. 

The  foregoing  points,  relating  to  the  physical  conditions  which 
belong  to  the  period  of  effusion  in  pericarditis,  are  involved  in  the 
circumstances  distinctive  of  the  signs  furnished  by  percussion  in 
this  disease.     The  most  distinctive  circumstance  is  that  already 


31-i    IXFLAM.MATOEY  AFFECTIONS  OF  THE  HEART. 

mentioned,  viz.,  an  area  of  prtecordial  dulness  corresponding  to  the 
pyriform  shape  of  the  pericardial  sac,  commencing  at  the  sixth 
costal  cartilage  or  intercostal  space,  and  extending  upward  to  the 
second  or  first  rib.  If  the  sac  be  distended  to  nearly  or  quite  its 
normal  capacity,  and  no  other  morbid  conditions  are  present  to 
obscure  the  physical  signs,  its  situation  and  shape  may  be  delineated 
upon  the  chest  with  less  difficulty  than  the  space  occupied  by  the 
heart  in  cases  of  enlargement,  in  consequence  of  the  dulness  and 
sense  of  resistance  being  more  marked.  In  cardiac  enlargement, 
the  area  of  dulness  does  not  present  the  pyriform  shape  which 
characterizes  that  due  to  pericardial  effusion.  It  corresponds  to 
the  form  and  situation  of  the  heart.  The  area  is  extended  chiefly 
in  a  lateral  direction  below  the  third  rib,  and  especially  to  the  left 
of  the  sternum,  whilst  the  extension  is  vertical  rather  than 
horizontal  when  the  pericardial  sac  is  distended  with  liquid.  The 
distinction  is  marked  if  the  accumulation  of  liquid  be  sufficient  to 
distend  the  sac.  It  is  less  so,  if  the  sac  be  but  partially  filled.  The 
area  of  dulness  is  then  widened  from  the  base  of  the  prajcordial 
region,  upward,  to  a  greater  or  less  extent,  in  proportion  to  the 
quantity  of  liquid.  This  lateral  enlargement,  however,  is  arrested, 
after  reaching  a  certain  distance,  and,  as  the  accumulation  goes  on, 
the  dulness  extends  upward  above  the  normal  boundary  of  the  base 
of  the  heart.  When  the  pericardial  sac  is  filled,  the  situation  and 
shape  of  the  area  of  dulness,  as  determined  by  percussion,  are 
almost  sufficient  for  the  diagnosis;  but  if  the  sac  be  but  partially 
filled,  the  signs  obtained  by  percussion  must  be  taken  in  connection 
with  those  furnished  by  other  methods  of  exploration.  A  moderate 
amount  of  liquid  will  widen  the  area  of  dulness.  Dr.  Walshe  states 
that  four  ounces  are  sufficient.  To  be  appreciable,  however,  by 
percussion,  when  the  sac  is  but  partially  filled,  the  pra3Cordia  must 
have  been  examined  before  the  efi'usion  occurred,  and  the  fact  of 
enlargement  thus  determined  by  comparison.  The  degree  of 
dulness  and  sense  of  resistance  are  to  be  taken  into  account.  The 
dulness  when  the  pericardial  sac  is  distended,  may  amount  nearly, 
or  quite  to  flatness,  and  the  elasticity  of  the  ribs  is  diminished  in  a 
notable  manner.  These  effects  are  much  more  strongly  marked  in 
cases  of  chronic  pericarditis  with  large  effusion. 

A  circumstance  highly  distinctive  of  liquid  accumulation  in 
pericarditis,  is  the  variation  in  the  extent  of  dulness  at  different 
periods  during  the  course  of  the  disease.  Effusion  often  taking 
place  rapidly,  if  the  pra3Cordia  have  been  examined  prior  to  its 


PERCUSSION    IN    ACUTE    PERICARDITIS.  315 

occurrence,  a  remarkable  enlargement  of  the  area  of  dulness  is 
sometimes  observed  after  the  lapse  of  a  few  hours.  This  enlargement 
may  be  found  to  have  been  progressive  at  successive  examinations 
until  it  reaches  a  certain  extent,  where  it  may  remain  stationary 
for  a  greater  or  less  period,  and  then  decrease  more  or  less  rapidly. 
Fluctuations  from  day  to  day  are  not  infrequently  observed,  the 
extent  of  dulness  now  increasing  and  now  diminishing,  until,  at 
length,  if  the  termination  of  the  disease  be  favorable,  it  is  reduced 
to  the  normal  limits.  On  the  other  hand,  the  dulness  from  cardiac 
enlargement  is  not  developed  thus,  as  it  were,  under  the  eyes  of  the 
observer.  Its  extension  is  so  gradual  as,  in  general,  to  be  imper- 
ceptible on  comparative  examinations  made  after  intervals  of  weeks 
and  even  months.  It  never  fluctuates,  nor  diminishes  in  extent. 
In  cases  of  pericarditis,  the  daily  employment  of  percussion  is  highly 
useful  in  determining  not  only  the  existence,  or  otherwise,  of  effu- 
sion, but  its  increase,  diminution,  and  final  disappearance.  Infor- 
mation concerning  these  points  may  influence  considerably  the 
treatment  of  the  disease,  as  well  as  the  prognosis. 

Another  distinctive  circumstance  is  derived  from  the  relation  of 
the  area  of  dulness  to  the  point  of  apex-beat  of  the  heart.  In  cases 
of  cardiac  enlargement,  the  beat  of  the  heart  is  felt  in  the  lower 
limit  of  this  area.  This  limit  is  often  defined  by  tympanitic  reso- 
nance due  to  gas  in  the  stomach.  In  cases  of  considerable  peri- 
cardial effusion  in  which  the  apex-beat  is  felt,  it  is  raised  above  the 
lower  border  of  the  area  of  dulness  from  the  presence  of  liquid. 
Percussion  below  the  apex-beat  yields  a  dull  or  flat  sound  for  a 
certain  distance,  before  a  gastric  tympanitic  resonance  is  reached. 
This  test  is  available  in  some  cases,  but  not  invariably.  It  requires 
that  the  apex-beat  shall  be  appreciable  either  by  the  eye  or  touch, 
and  the  presence  of  gas  in  the  stomach.  The  percussion  should  be 
light  or  superficial. 

The  signs  furnished  by  percussion  in  pericarditis,  as  already 
stated,  relate  to  the  effusion  of  liquid  incident  to  the  disease.  Prior 
to  effusion,  and  subsequently,  this  method  of  examination  does  not 
afford  important  information  except  in  a  negative  point  of  view. 
The  presence  of  lymph,  it  is  true,  increases  somewhat  the  size  of 
the  heart,  but  not  to  an  extent  to  give  rise  to  an  appreciable  en- 
largement of  the  area  of  dulness.  The  availability  of  these  signs 
when  the  pericardial  effusion  is  abundant,  may  be  impaired  or 
destroyed  by  the  coexistence  of  other  morbid  conditions  affecting 
the  adjacent  parts.     If  the  pericarditis  be  accompanied  by  pleurisy 


316  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

witli  effusion,  it  is  difficult,  or  impossible,  to  define  the  dulness  due 
to  the  dilated  pericardium.  Difficulty  and  error,  were  the  signs 
furnished  by  percussion  to  be  exclusively  relied  upon,  would  be 
likely  to  arise,  as  indicated  by  Dr.  Walshe,  from  an  aneurismal  sac 
at  the  arch  of  the  aorta,  or  a  small  mediastinal  tumor,  or  even  a 
superabundance  of  fat  just  above  the  third  left  cartilage,  all  of 
which,  in  connection  with  enlargement  of  the  heart,  may  simulate 
the  pyramidal  form  of  the  area  of  dulness  which  is  characteristic 
of  distension  of  the  pericardial  sac. 

Signs  furnished  by  auscultation. 

The  auscultatory  phenomena  in  cases  of  pericarditis,  are  of  great 
importance  in  their  relations  to  diagnosis.  It  is  more  especially 
with  respect  to  these,  that  the  knowledge  acquired  within  late  years 
has  been  so  useful  in  enabling  the  physician  to  determine,  with 
positiveness,  the  existence  of  the  disease.  The  signs  furnished  by 
auscultation  relate,  firsts  to  the  development  of  new  or  adventitious 
sounds,  generally  known  as  attrition  or  friction-sounds ;  second,  to 
abnormal  modifications  of  the  heart-sounds;  and,  thii-d,  to  respiratory 
and  vocal  sounds  in  proximity  to  the  prtecordial  region. 

The  sounds  of  attrition  or  friction  are  also  called  exocardial, 
pericardial,  and  peripheral  sounds.  The  term  friction-sound  is  the 
most  simple,  and  sufficiently  expressive.  The  occurrence  of  a 
friction- sound  in  pericarditis  was  first  noticed  by  a  French  observer, 
M.  Collin.  The  sound  observed  by  him,  he  compared  to  the  creak- 
ing of  new  leather  (hruit  de  cuir  neuf),  and  he  attributed  it  to  an 
unnatural  dryness  of  the  inflamed  pericardium.  A  sound  re- 
sembling the  crackling  of  parchment  was  subsequently  observed  by 
Broussais.  But  the  inauguration  of  friction-sounds  as  constituting 
a  frequent  physical  sign  of  pericarditis,  is  to  be  dated  from  a  publi- 
cation by  Dr.  Stokes  in  1834.  The  attention  of  Dr.  "Watson,  of 
London,  was  directed  to  these  sounds  simultaneously  with  Dr. 
Stokes,  and  they  were  shortly  afterward  observed  by  Bouillaud, 
without  his  being  aware  of  the  prior  observations  of  his  British 
co-laborers. 

The  motions  of  the  heart  in  its  contractions  and  dilatations,  but 
more  particularly  its  movements  of  rotation,  involve  friction  of  the 
opposed  pericardial  surfaces.  But  in  the  normal  condition  of  the 
membrane,  a  friction-sound,  as  a  rule,  is  not  audible,  exclusive  of 
the  element  of  impulsion  in  the  first  sound,  which  has  been  de- 


AUSCULTATION    IN    ACUTE    PERICARDITIS.  317 

scribed  in  Chapter  I.  of  this  work.  This  element  in  some  persons 
has  somewhat  of  a  friction  character ;  and  I  have  occasionally  dis- 
covered, in  auscultating  the  heart,  a  slight  rubbing  or  grazing 
sound  accompanying  the  systole,  when  there  were  no  grounds  for 
suspecting  any  cardiac  disease.  These  exceptions  to  the  general 
rule  do  not  impair  the  practical  value  of  the  physical  sign  as  an 
indication  of  disease.  The  physical  conditions  necessary  for  the 
production  of  a  morbid  friction-sound,  are  due  to  the  products  of 
inflammation  deposited  upon  the  pericardial  surfaces,  by  which  they 
are  roughened  and  caused  to  adhere,  instead  of  gliding  smoothly 
and  noiselessly  upon  each  other.  These  products  differ  in  different 
cases,  and  in  different  periods  of  the  disease  in  the  same  case,  as 
regards  abundance,  density,  disposition,  etc.  The  character  of  the 
friction-sound  is  doubtless  affected  by  these  differences,  but  it  is 
difficult  or  impossible  to  determine  for  each  variety  of  sound  a 
special  significance,  by  which  may  be  recognized,  with  precision, 
corresponding  variations  in  the  physical  conditions.  Like  endo- 
cardial murmurs,  the  sounds  are  sometimes  rough,  and  sometimes 
comparatively  soft.  The  latter  convey  the  idea  of  a  gentle  grazing 
or  rubbing;  the  former  are  distinguished  as  grating,  scraping,  or 
rasping  sounds,  and  denote  a  more  abundant  and  dense  deposit  of 
lymph.  The  creaking  sound  described  by  Collin  is  attributed  to 
the  stretching  of  lymph  which  has  led  to  partial  adhesions.  Dr. 
Walshe  thinks  that  it  may  be  produced  when  the  surfaces  are  so 
closely  agglutinated  that  attrition  or  separation  is  physically  im- 
p)ossible,  being  caused  by  the  bending  and  crumpling  of  tough, 
false  membranes.  Occasionally,  according  to  this  observer,  the 
sounds  have  a  clicking  character.  A  continuous  rumbling  sound 
is  sometimes  heard,  which  is  supposed  to  be  due  to  the  presence  of 
a  small  quantity  of  liquid  with  which  soft  lymph  is  commingled. 
A  churning  or  splashing  sound  occurring  after  a  penetrating  wound 
of  the  chest,  causing  a  small  aperture  into  the  pericardium,  but 
without  giving  rise  to  pericarditis,  was  described  to  me  by  Dr. 
Knapp,  of  Louisville,  due  probably  to  the  escape  of  a  small  quan- 
tity of  blood  into  the  pericardial  sac.  To  attempt  to  describe  all 
the  varieties  of  friction  sounds,  and  apply  to  them  different  names, 
Avould  render  the  subject  needlessly  complicated.  It  is  important 
to  know  the  diversities  of  character  which  they  assume,  only  so  far 
as  this  knowledge  is  instrumental  in  aiding  in  their  recognition  at 
the  bedside. 

A   friction   sound    may  accompany  the   systolic   and   diastolic 


318  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

movements  of  the  heart,  separately  or  combined.  In  the  mnjority 
of  instances  it  accompanies  both  movements,  or,  in  other  words,  is 
double.  Hence,  it  was  described  by  Dr.  Watson  under  the  name 
of  the  "to-and-fro  rubbing  sound."  When  single,  it  is  generally 
systolic.  A  diastolic  friction-sound  occurring  alone  must  be  ex- 
ceedingly rare.  A  double  sound  may  be  heard  in  certain  situa- 
tions, and  only  a  single  sound  in  other  situations.  The  intensity 
varies  in  different  cases,  and  even  at  different  periods  in  the  same 
case,  within  wide  limits.  In  some  instances  so  faint  as  to  be 
discovered  only  with  the  closest  attention,  it  is,  in  other  instances, 
sufficiently  loud  to  be  heard  with  the  ear  removed  at  a  short 
distance  from  the  stethoscope.  Between  these  extremes  there  is 
every  gradation  of  intensity.  The  systolic  friction-sound  may  be 
intense,  and  the  diastolic  comparatively  feeble.  The  converse  of 
this  must  be  rare.  The  intensit}^  will  depend,  in  a  great  measure, 
upon  the  physical  conditions  which  give  rise  to  the  sound ;  but 
also  upon  the  force  of  the  heart's  movements.  Variation,  in  the 
latter  respect,  at  different  times  in  the  same  case,  will  affect  the 
intensity  of  the  sound.  Bleeding  and  debilitating  remedies,  by 
weakening  the  heart,  have  been  observed  to  lessen  the  intensity  in 
a  marked  degree.  On  the  other  hand,  the  intensity  is  notably 
great  when  pericarditis  supervenes  on  hj^pertrophy  of  the  heart. 

Under  what  circumstances  are  friction-sounds  developed  within 
the  pericardium,  in  cases  of  pericarditis?  In  order  for  their  pro- 
duction, the  visceral  and  parietal  surfaces  must,  of  course,  come  into 
contact  durino-  the  movements  of  the  heart.     The  accumulation  of 

O 

liquid  in  the  pericardial  sac,  separates  these  surfaces  to  a  greater  or 
less  extent,  but  does  not  necessarily  prevent  them  from  coming  into 
contact.  The  movements  of  the  heart  may  bring  these  surfaces 
together  at  certain  points,  and,  in  a  recumbent  position,  the  organ 
naturally  gravitates  to  the  bottom  of  the  liquid,  and  rests  upon  the 
depending  portion  of  the  sac.  Hence,  friction  sounds  are  by  no 
means  uniformly  arrested  by  an  abundant  liquid  effusion.  They 
are  observed  in  some  cases  in  which  the  quantity  of  liquid  is  ex- 
tremely large.  In  many,  perhaps  in  the  majority  of  cases,  however, 
they  do  disappear  during  the  period  of  effusion,  which  is  probably 
owing  to  weakness  of  the  heart's  action,  and  not  to  an  entire  sepa- 
ration of  the  pericardial  surfaces.  The  sounds  are  most  likely  to 
be  produced  anterior  and  subsequent  to  the  period  of  effusion. 
They  may  be  developed  very  soon  after  the  commencement  of  the 
disease.     Dr.  Walshe  states  that  friction  was  detected  in  a  case  in 


AUSCULTATION    IN    ACUTE    PEEICAEDITIS.  319 

which   fatal   perforation  of  the  oesophagus  and   pericardium  was 
produced  in  the  attempt  to  swallow  a  sword,  thirty  minutes  after 
the  accident.     Here,  the  sound  was  probably  due  to  the  presence 
of  blood  in  the  pericardial  sac.     I  have  observed  it  well  marked 
six  hours  after  the   sudden   occurrence   of  pain,  etc.,  denoted   an 
attack  of  pericarditis.     It  is  rare  that  patients  are  seen  at  an  earlier 
period  in  the  disease.     In  that  case,  the  disease  was  developed  in 
hospital,  in  connection  with  Bright's  disease.    It  has  been  supposed 
to  occur  prior  to  the  exudation  of  lymph,  and  to  be  dependent  on 
dryness  of  the  •membrane.    This  must  be  considered  as  conjectural. 
Dr.  AValshe  states  that  he  has  known  mere  vascularity  of  a  very 
small  surface,  without  a  particle  of  lymph,  to  produce  a  ftiint  rub- 
bing noise.     This,  however,  is  sometimes  observed  when  the  mem^ 
brane  may  be  presumed  to  be  entirely  healthy.    As  a  rule,  to  which 
there  are  very  few  exceptions,  the  presence  of  a  friction-sound  im- 
plies deposit  of  lymph  in  more  or  less  abundance.     Moreover,  as  a 
rule,  a  friction-sound  is  developed  whenever  exudation  of  lymph 
takes  place,  and  continues  up  to  the  period  of  effusion,  if  not  into 
this  period.     The  value  of  the  sign  in  diagnosis  depends,  in  a  great 
measure,  on  this  important  fact.     Clinical  observation  shows  that 
the  absence  of  a  friction-sound  in  pericarditis,  if  auscultation   be 
employed  with  care  from  an  early  period  of  the  disease,  is  a  rare 
exception  to  the  general  rule.     When  not  observed,  assuming  pro- 
per care  and  ability  in  the  observer,  it  is  probable  that,  in  most 
instances,  it  existed  prior  to  the  case  coming  under  observation.    It 
may  soon  disappear,  after  becoming  developed,  in  consequence  of 
weakness  of  the  heart  and  liquid  effusion.     Dr.  Walshe  states  that 
he  has  known  it  to  appear  and  to  disappear  finally,  within  the 
space  of  six  hours.     If  it  disappear  during  the  period  of  effusion,  it 
often  returns  after  the  liquid  is  absorbed,  and  the  pericaixlial  sur- 
faces again  come  freely  into  apposition.     This  returning  friction- 
sound,  in  conjunction  with  the  phj'sical  signs  obtained  by  percus- 
sion, becomes  evidence  of  the  removal  of  the  liquid,  and  is,  there- 
fore, of  favorable  omen.    It  is,  however,  less  constant  at  this  period 
than  during  the  period  preceding  effusion,  in  this  respect  differing 
from  the  friction-sounds  incident  to  pleuritis,  the  latter  being  deve- 
loped much  oftener  after,  than  before  the  stage  of  effusion.     The 
character  of  the  sound  developed  in  the  third  period  of  the  disease 
may  differ  from  that  in  the  first  period.    If,  prior  to  effusion,  it  was 
rubbing,  grazing,  or  churning,  it  may  become,  after  absorption, 
rasping,  grating,  or  creaking.     Adhesion  of  the  pericardial  surfaces 


320  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

generally  arrests  the  sound,  but  this  rule  is  not  invariable.  Stretcb- 
ing  of  newly-formed  tissue  and  bending  of  tbe  exudation  matter, 
may  give  rise  to  a  creaking  sound.  The  disappearance  of  the  sound 
may  be  abrupt,  or  gradual,  generally  tbe  latter.  Like  pleural  fric- 
tion-sound, it  may  continue  for  a  considerable  time  after  convales- 
cence and  apparent  recovery.  Dr.  Walsbe  refers  to  an  instance, 
under  bis  observation,  of  its  persistence  for  three  months,  continu- 
ing long  after  the  patient's  discharge  from  the  hospital,  and  when 
he  seemed  to  be  perfectly  restored  to  health. 

Friction-sounds  are  to  be  discriminated  at  tha  bedside  from 
endocardial  murmurs.  According  to  the  testimony  of  numerous 
observers,  this  is  sometimes  extremely  difficult.  The  two  are  often 
confounded  by  those  who  assume  to  employ  physical  exploration, 
with  an  imperfect  knowledge  of  the  subject.  But  with  proper  care, 
and  an  acquaintance  with  the  differential  points  involved  in  the 
discrimination,  the  instances  are  rare  in  which  a  practical  ausculta- 
tor  is  much  embarrassed.  The  distinctive  circumstances  are  im- 
portant to  be  considered.  In  many  instances  the  intrinsic  character 
of  the  sound  is  sufficient,  in  itself,  to  mark  the  distinction.  The 
sound  convej^s  to  the  mind  the  idea  of  the  rubbing  together  of 
rough  surfaces.  This,  however,  is  by  no  means  to  be  relied  upon 
to  the  exclusion  of  other  distinctive  circumstances.  A  rough  val- 
vular murmur  sometimes  simulates  closely,  so  far  as  the  character 
of  the  sound  is  concerned,  a  friction-sound.  Other  points  are  to  be 
taken  into  account.  Friction-sounds  are  generally  double,  i.  e., 
systolic  and  diastolic.  This  is  a  point  of  minor  importance,  since 
double  endocardial  murmurs  are  not  very  infrequent.  Points  of 
much  greater  importance  relate  to  the  localization  and  diffusion  of 
friction-sounds  considered  relatively  to  endocardial  murmurs. 
Friction-sounds  are  usually  limited  within  the  space  occupied  by 
the  heart.  They  very  rarely  extend  beyond  the  borders  of  the 
organ.  In  general,  they  abruptly  cease  when  the  stethoscope  is 
removed  but  a  short  distance  without  the  boundaries  of  the  heart, 
although  they  may  be  quite  intense  everywhere  within  the  limits 
of  the  cardiac  region.  This  is  certainly  the  rule,  but  exceptions 
undoubtedly  do  occur.  With  endocardial  murmurs  the  rule  is 
otherwise.  These  are  generally  heard  with  greater  intensity  at  ^ 
points  removed  from  tbe  heart,  than  over  the  heart  itself.  Aortic 
murmurs  are  loudest  above  the  base  of  the  organ,  in  the  second 
intercostal  space.  Mitral  murmurs  are  usually  most  intense  to  the 
left  of  the  apex.     Both  mitral  and  aortic  murmurs  are  often  dif- 


AUSCULTATIOISr    IX    ACUTE    PERICARDITIS.  321 

fused  to  a  considerable  distance  from  the  heart,  the  latter  alone  as 
far  as  the  carotids,  and  the  former  not  infrequently  over  the  left 
lateral  and  posterior  surfaces  of  the  chest.  The  maximum  of 
intensity  of  pericardial  friction-sounds  is  generally  over  the  body 
of  the  heart,  within  the  superficial  cardiac  region.  They  are  fre- 
quently limited  to  this  region,  or  even  to  a  portion  of  it,  which 
may  be  either  towards  the  base  or  apex,  oftener  the  former  when 
they  are  thus  circumscribed.  It  is  only  in  some  rare  instances  that 
endocardial  murmurs  are  heard  exclusively  within  the  superficial 
cardiac  region.  This,  however,  is  sometimes  the  case  with  mur- 
murs which  I  have  called  intra-ventricular,  as  distinguished  from 
those  produced  at  the  orifices.'^  These  points  are  highly  distinctive. 
Friction-sounds  do  not  observe  rhythmical  relations  to  the  heart- 
sounds  as  do  endocardial  murmurs.  An  endocardial  murmur  has 
a  certain  connection  with  one  of  the  sounds  of  the  heart,  and  this 
connection  is  uniformly  maintained.  A  friction-sound,  on  the 
other  hand,  frequently  seems  to  occur  discordantly,  as  regards  the 
heart-sounds,  varying  in  rhythm  irrespective  of  the  latter.  Varia- 
bleness is  a  distinctive  trait  of  friction-sounds,  as  compared  with 
endocardial  murmurs.  The  latter  undergo  but  little  change  with 
successive  beats  of  the  heart ;  while  the  former  vary,  even  during 
the  time  occupied  in  an  examination,  as  regards  intensity,  the 
occurrence  of  one  or  two  sounds  with  a  single  beat,  the  character 
of  the  sounds  as  regards  roughness  and  softness,  the  situation  in 
which  they  are  loudest,  etc.  Their  variableness,  as  regards  dura- 
tion, is  distinctive.  Endocardial  murmurs  are  generally  persisting. 
The  latter  are  rarely  affected  materially  by  change  in  the  position 
of  the  patient.  Friction-sounds  are  not  only  more  intense  in  cer- 
tain positions  than  in  others,  but  they  are  sometimes  heard  only 
when  the  body  is  in  a  particular  posture.  Thus,  they  may  be 
apparent  when  the  patient  lies  on  the  back,  and  disappear  when 
he  is  sitting,  or  vice  versa.  Their  intensity  may  be  increased  or 
diminished  by  inclining  the  body  backwards  or  forwards.  The 
explanation  of  this  is,  that  in  certain  positions  the  pericardial 
surfaces  are  brought  into  contact  at  points  where  the  physical 
conditions  are  most  favorable  for  the  production  of  sound.  These 
variations  in  different  positions  are  observed  more  especially  when 
more  or  less  liquid  effusion  is  contained  within  the  pericardial  sac. 
Friction-sounds   may  be  discovered  by  auscultating   in   difi:erent 

'  Vide  Chapter  IV.  page  202. 
21 


322  INFLAMMATORY    AFFECTIONS    OF    THE    HEAKT. 

positions,  when,  were  the  examination  limited  to  one  position, 
they  would  fail  to  be  apparent.  Another  distinctive  circumstance 
is  their  apparent  proximity  to  the  ear  of  the  auscultator.  They 
seem  to  be  superficially  seated,  resembling  often  the  sound  produced 
by  friction  of  the  clothing  upon  the  stethoscope.  This  resemblance 
is  sometimes  so  striking  that  the  observer  looks  to  see  whether  the 
sound  be  not  actually  thus  produced.  An  exception  to  this  rule 
is,  when  a  friction-sound  is  produced  on  the  posterior  surface  of 
the  heart.  On  the  other  hand,  endocardial  murmurs,  as  a  rule, 
appear  to  emanate  from  points  more  removed  from  the  ear,  or 
situated  deeper  within  the  chest.  This  is  a  highly  distinctive 
point. 

Finally,  as  indicated  first  by  Dr.  Sibson,  firm  pressure  with  the 
stethoscope  is  found  generally,  but  more  especially  in  young  sub- 
jects, to  intensify  friction-sounds.  It  does  this  partly  by  increasing 
the  conduction,  and  in  part  by  displacing  the  stratum  of  liquid, 
bringing  the  pericardial  surfaces  into  closer  apposition,  and  render- 
ing the  walls  of  the  chest  more  resisting.  In  this  way,  a  friction 
sound  which  has  disappeared  in  consequence  of  effusion,  may 
sometimes,  according  to  Dr.  Sibson,  be  reproduced.  An  effect  of 
pressure  is  sometimes  to  change  the  character  of  the  sound,  con- 
verting it  from  a  soft  to  a  rough  sound.  As  stated  by  Dr.  Walshe, 
the  pitch  may  be  raised.  Endocardial  murmurs  are  not  intensified 
to  the  same  extent  by  pressure.  It  is  incorrect  to  say  that  they 
are  in  no  degree  intensified.  Their  intensity  is  augmented  in  so 
far  as  the  conduction  is  increased.  It  is  in  this  way  alone,  proba- 
bly, that  pressure  intensifies  endocardial  murmurs.  The  difference 
in  the  result  in  the  two  cases,  constitutes  this  an  important  point  of 
distinction.  Attention  to  the  several  circumstances  just  mentioned 
renders,  in  most  instances,  the  discrimination  between  friction- 
sounds  and  endocardial  murmurs  sufficiently  easy.  It  is,  however, 
to  be  borne  in  mind  that  endocardial  murmurs  and  pericardial 
friction-sounds  are  frequently  present  in  combination,  pericarditis 
coexisting  with  endocarditis,  or  the  heart  being  affected  with  val- 
vular lesions  antecedent  to  the  development  of  the  pericarditis.  It 
has  been  supposed  that  the  deposit  of  lymph  at  the  base  of  the  heart 
and  about  the  large  vessels  within  the  pericardium,  or  the  accumu- 
lation of  a  large  quantity  of  liquid,  may  sometimes  give  rise,  by 
pressure  on  the  vessels,  to  endocardial  murmur.  This  is  doubtful. 
The  frequent  combination  of  the  latter  with  the  physical  signs  of 


AUSCULTATION    IN    ACUTE    PERICARDITIS.  323 

pericarditis,  is  to  be  explained  by  the  coexistence  of  endocardial 
inflammation,  or  valvular  lesions. 

Pericardial  friction-sounds  are  to  be  discriminated,  at  the  bed- 
side, from  those  produced  by  the  rubbing  together  of  the  pleural 
surfaces.  Both  pleural  and  pericardial  friction-sounds  may  be 
combined,  since  pleuritis  and  pericarditis  are  frequently  associated. 
The  pleural  sounds  caused  by  the  respiratory  movements,  are  readily 
distinguished  from  the  pericardial,  by  the  difference  in  rhythm.  A 
simple  expedient  serves  to  remove  any  doubt  as  to  their  dependence 
on  the  action  of  the  heart  or  lungs,  viz.,  causing  the  patient  to 
suspend,  for  a  moment,  the  acts  of  breathing ;  if  the  sounds  persist, 
they  are  of  cardiac  origin. 

But  pleural  friction-sound  may  be  produced  by  the  action  of  the 
heart.  The  friction  here  is  lutthout,  instead  of  ivithin  the  pericardial 
sac.  Dr.  Addison,  Dr.  Stokes,  and  others,  have  reported  cases 
exemplifying  the  occasional  production,  in  cases  of  pleuritis,  of  a 
cardiac  pleural  friction-sound,  which  may  lead  the  auscultator  into 
the  error  of  supposing  that  pericarditis  exists  when  there  is  no 
cardiac  disease.  I  can  bear  testimony  to  this  liability  to  error.  In 
a  case  of  pleurisy,  with  considerable  effusion,  which  came  under 
my  observation  in  the  New  Orleans  Charity  Hospital,  a  well-marked, 
pretty  intense,  and  rough  cardiac  friction-sound  was  apparent  in 
the  prEecordia.  It  continued  when  the  respiratory  movements  were 
suspended.  It  existed  within  an  area  from  three  to  four  inches  in 
diameter,  and  was  noted  to  extend  somewhat  beyond  the  left  border 
of  the  heart.  It  varied  in  intensity  with  different  beats  of  the  heart, 
and  with  occasional  beats  was  wanting.  It  was  sometimes  double 
and  sometimes  single,  in  the  latter  case  being  systolic.  It  was 
intensified  by  firm  pressure  with  the  stethoscope.  It  was  most 
marked  at  the  end  of  a  deep  inspiration.  This  sound  continued 
for  several  days,  and  was  listened  to  by  a  large  number  of  physi- 
cians and  students,  who  were  accustomed  to  visit  the  ward,  as  an 
excellent  specimen  of  a  pericardial  friction-sound.  Delirium  tre- 
mens was  developed  in  the  case,  and  the  patient  died.  I  expected 
to  find  pericarditis  associated  with  the  pleurisy,  but,  on  examination, 
after  death,  the  pericardial  sac  contained  a  moderate  quantity  of 
transparent  serum,  and  the  membrane  was  perfectly  healthy.  The 
heart  was  in  all  respects  normal ;  the  endocardium  presented  a 
natural  appearance,  and  no  valvular  lesions  existed.  The  left 
pleural  sac  contained  a  large  quantity  of  turbid  serum.  The  lung 
extended  downward,  in  front  to  the  level  of  the  nipple.     It  was 


824         INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

connected  by  tender  adhesions  to  the  outer  surface  of  the  pericar- 
dium, and  the  costal  and  pleural  surfaces  were  also  united  by  tender 
adhesions.  The  friction-sound  was  evidently  a  cardiac  pleural 
sound,  produced  either  by  the  rubbing  together  of  the  outer  surface 
of  the  fibrous  sac  inclosing  the  heart  against  the  adjacent  lung  (which 
overlaid  the  heart),  or  of  the  opposed  pleural  surfaces  above  the  heart. 
In  view  of  this  case,  I  am  prepared  to  concur  in  the  opinion  of  Dr. 
Addison,  that  "auscultation  will  not  always  enable  us  to  distin- 
guish a  friction-sound  produced  iviihin,  from  a  friction -sound  pro- 
duced without  the  pericardial  sac,'"  Walshe  gives  the  following  as 
the  circumstances  which  argue  in  favor  of  friction  of  cardiac  rhythm 
being  of  pleural,  and  not  of  pericardial  origin  :  "  The  limitation  of 
the  sound  to  either  edge,  generally  the  left,  of  the  cardiac  region ; 
fixity  in  one  or  more  particular  spots ;  cessation  complete,  or,  what 
is  more  common,  occasional,  with  certain  beats  of  the  heart,  when 
the  breath  is  held;  and  marked  unsteadiness  in  the  intensity  and 
quality  of  the  friction-sound."  These  circumstances  were  not  fully 
available  for  the  discrimination  in  the  case  which  I  have  cited.  It 
may  be  added  to  the  account  of  the  case  that,  in  making  clinical 
remarks,  attention  was  called  to  the  occasional  occurrence  of  a  car- 
diac pleural  friction-sound,  but  I  confess  that  I  did  not  regard  the 
case  as  furnishing  an  illustration  till  the  chest  was  examined  after 
death.  The  sound  was  not  limited  to  the  edge  of  the  cardiac  region, 
but  was  heard  over  an  area  of  from  three  to  four  inches  in  diameter. 
It  extended,  however,  beyond  the  left  border  of  the  heart.  It  did 
not  cease  when  the  breath  was  held,  but  it  was  most  marked  at  the 
end  of  a  full  inspiration,  while  pericardial  friction-sounds  are  usu- 
ally most  marked  at  the  end  of  the  act  of  expiration.  "Unsteadi- 
ness in  the  intensity  and  quality  of  the  friction-sound"  certainly 
characterizes  a  true  pericardial  friction-sound  in  certain  cases. 

In  conclusion,  a  pericardial  friction-sound,  as  regards  diagnostic 
significance,  is,  perhaps,  the  most  definite  and  reliable  of  all  the 
signs  obtained  by  physical  exploration  of  the  chest.  Exclusive  of 
cases  in  which  the  pericardium  is  perforated,  so  that  a  small  quantity 
of  blood  escapes  into  the  sac  (which  is  not  necessarily  followed  by 
inflammation),  it  is  pathognomonic  of  pericarditis.  This  can  hardly 
be  said  of  any  other  physical  sign  pertaining  to  the  heart  or  the 
respiratory  oi'gans. 

The  heart-sounds  undergo   certain  abnormal   modifications  in 

'  Guy's  Hospital  Reports,  vol.  iv.     From  Belliiigham,  op.  cit. 


AUSCULTATION    IN    ACUTE    PERICAEDITIS.  325 

pericarditis.  Early  in  the  disease,  prior  to  the  period  of  liquid 
effusion,  they  are  either  not  materially  affected,  or  intensified  by 
the  excited  action  of  the  heart.  An  abundant  accumulation  of 
liquid  occasions  marked  modifications,  more  especially  of  the  first 
or  systolic  sound.  The  impulsion  of  the  apex  against  the  thoracic 
walls  being  either  prevented  or  greatly  weakened,  the  element  of 
the  first  sound,  which  has  been  designated  the  element  of  impulsion, 
is  impaired  or  lost ;  the  valvular  element  is  left  isolated,  or  it 
becomes  predominant.  Hence,  the  first  sound  is  enfeebled,  and 
shortened,  resembling  tlie  second  sound  in  quality  and  duration,  but 
less  intense.  The  second  sound  is  affected  only  as  regards  intensity, 
and,  in  this' respect,  much  less  than  the  first  sound.  The  second 
sound,  therefore,  over  the  whole  pra3cordia,  is  the  accentuated 
sound.  It  is  sometimes  the  only  sound  discoverable,  the  first 
sound  being  suppressed.  The  muscular  weakness  of  the  heart, 
arising  from  compression  and  the  paralyzing  influence  of  the  peri- 
cardial inflammation,  favors  these  effects.  Both  sounds  appear  to 
be  further  removed  from  the  ear  than  in  health,  in  other  words, 
they  are  more  distant.  This  sense  of  distance  is  more  obvious 
when  the  patient  is  in  certain  positions  than  in  others.  It  is  most 
marked  when  the  patient  lies  on  the  back,  because  the  heart  is  then 
actually  further  removed  from  the  anterior  walls  of  the  chest.  The 
apparent  distance  diminishes  perceptibly  when  the  sitting  posture 
is  assumed,  and  still  more  when  the  patient  leans  forward.  After 
the  removal  of  the  liquid,  the  normal  characters  of  the  heart-sounds 
return,  except  so  far  as  they  may  be  modified  by  weakness  of  the 
organ.  In  these  remarks,  it  is  assumed  that  valvular  lesions  are 
not  present.  These  will,  of  course,  be  likely  to  affect  the  sounds 
of  the  heart,  irrespective  of  the  pericardits.  The  abnormal  modifi- 
cations due  to  the  latter,  are  not  without  interest;  but,  as  compared 
with  other  signs,  they  are  of  minor  importance. 

Auscultation  of  the  respiration  and  voice  may  be  employed  in 
conjunction  with  percussion,  in  order  to  aid  in  determining  the 
space  occupied  by  the  pericardial  sac  when  distended  with  liquid. 
The  limits  to  which  the  respiratory  murmur  extends  in  a  direction 
toward  the  prtecordia,  in  some  cases  serves  to  define  the  boundary 
of  this  space.  If  these  limits  coincide  with  the  loss  of  vesicular 
resonance  on  percussion,  the  two  methods  mutually  confirm  each 
other,  as  regards  the  accuracy  of  their  respective  results.  Vocal 
resonance  is  frequently  more  available  for  this  purpose  than  the 
respiratory  murmur.      It  may  be  found  to  cease  abruptly  where 


326  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

(lulness  or  flatness  gives  place  to  vesicular  resonance  on  percussion. 
These  different  classes  of  signs,  thus,  concur  in  delineating  the  line 
of  demarcation  between  the  lungs  and  pericardium.  This  applica- 
tion of  auscultation  presupposes  that  the  lungs  are  free  from 
disease.  Auscultation  of  the  respiration  and  voice  is  obviously 
important  in  determining  the  nature  and  extent  of  the  pulmonary 
affections  which  may  be  associated  with  pericarditis. 

Signs  furnished  by  palpation. 

These  are  important  in  the  diagnosis  of  pericarditis.  Prior  to 
the  period  of  effusion,  the  beating  of  the  heart  is  usually  found,  on 
palpation,  to  be  abnormally  forcible,  violent,  diffused  over  a  larger 
area  than  in  health,  and  sometimes  tumultuous.  The  action  of  the 
heart,  as  thus  ascertained,  may  be  in  striking  contrast  with  the 
pulse.  Hope  enjoins  the  rule  of  habitually  placing  the  hand  upon 
the  prgecordia  in  all  cases  of  disease,  in  order  that  attention  may  be 
directed  to  the  heart  in  instances  in  which,  from  the  absence  of 
obvious  symptoms  referable  to  that  organ,  cardiac  disease  is  liable 
to  be  overlooked.  By  observing  this  rule,  pericarditis  may  some- 
times be  discovered  earlier  than  would  otherwise  be  the  case.  A 
practical  object  in  examining  the  prsecordia,  by  palpation,  prior  to 
effusion,  is  enforced  by  "Walshe,  viz.,  to  determine  the  situation  of 
the  apex-beat  with  reference  to  subsequent  comparisons.  "When 
eff'usion  takes  place,  the  apex  of  the  heart  is  raised  and  carried  to 
the  left.  The  point  of  apex-beat  which,  prior  to  eff'usion,  was 
situated  in  the  fifth  intercostal  space,  may  be  found,  after  eff'usion 
has  occurred,  to  be  raised  to  the  fourth  intercostal  space  and  carried 
to  the  vertical  line  of  the  nipple,  or,  possibly  beyond  this  line. 
This  change,  taken  in  connection  with  other  signs,  is  highly  signifi- 
cant of  pericardial  eff'usion.  But  it  must  be  recollected  that  causes 
other  than  pericardial  effusion  alter,  in  the  same  way,  the  point  of 
apex-beat,  for  example,  tympanitic  distension  of  the  stomach.  An 
abundant  accumulation  of  liquid  suppresses  all  impulse.  When 
the  beat  is  found  to  disappear,  after  having  been  previously  felt 
even  more  forcibly  than  in  health,  if  the  presence  of  liquid  have 
been  already  determined,  an  increased  amount  of  accumulation 
is  to  be  inferred ;  afterward,  as  absorption  of  the  liquid  goes  on, 
the  heart's  impulse  becomes  again  appreciable,  at  first  elevated 
above  its  normal  position,  and  it  may,  or  it  may  not,  subsequently 
fall  to  the  point  where  it  was  felt  prior  to  the  eff'usion  of  liquid. 


PALPATION    IN    ACUTE    PERICARDITIS.  327 

It  is  to  be  borne  in  mind  that  various  morbid  conditions,  other 
than  pericardial  effusion,  may  cause  suppression  of  the  apex-beat ; 
such  as  pleuritic  effusion,  pulmonary  emphysema,  dilatation  of  the 
heart,  fatty  degeneration,  etc.  Excluding  these,  the  following  series 
of  events  occurring  successively  in  connection  with  other  signs 
denoting  pericarditis,  becomes  highly  diagnostic:  increased  force 
of  the  apex-beat,  followed  by  diminished  force,  the  point  where  it 
is  felt  raised  and  carried  to  the  left,  suppression  of  the  beat,  and  its 
subsequent  reappearance  at,  or  somewhat  above  the  point  where  it 
is  felt  in  health. 

A  physical  sign  determined  by  palpation  is  a  sensible  vibration 
of  the  thoracic  walls  in  the  prsecordial  region,  caused  by  friction  of 
the  pericardial  surfaces  roughened  by  an  abundant  deposit  of  dense 
lymph.  The  sensation  communicated  to  the  hand  is  analogous  to 
that  which  accompanies  a  friction-sound  due  to  the  respiratory 
movements  in  some  cases  of  pleuritis.  This  sign,  first  described  by 
Stokes,  is  called  \k\.Q  'pericardial  friction- fremitus.  It  is  produced  by 
the  same  physical  conditions  which  give  rise  to  friction-sound,  and 
it  is  always  accompanied  by  the  latter.  It  occurs,  however,  only  in 
a  certain  proportion  of  the  cases  in  which  a  friction-sound  is  heard, 
and  it  rarely  continues  as  long  as  the  latter.  It  requires  a  greater 
degree  of  roughness  of  the  pericardial  surfaces  than  always  obtains 
in  pericarditis,  and,  also,  a  certain  amount  of  vigor  in  the  heart's 
movements.  It  occurs  prior  to  the  period  of  effusion,  but  very 
rarely  after  this  period,  the  movements  of  the  heart,  at  this  stage 
of  the  disease,  not  being  sufficiently  strong  to  produce  it.  It  is  not 
incompatible  with  a  small  amount  of  liquid  effusion,  but  it  invari« 
ably  ceases  when  the  quantity  of  liquid  is  large.  It  is  not  to  be 
confounded  with  the  purring  thrill  which  occurs  in  connection  with 
valvular  lesions.  It  is  also  to  be  discriminated  from  pleural  tactile 
fremitus.  The  latter,  being  produced  by  the  respiratory  movements, 
ceases  when  respiration  is  suspended;  while  pericardial  fremitus, 
being  produced  by  the  movements  of  the  heart,  is  not  arrested  by 
holding  the  breath.  The  sensation  of  rubbing,  or  friction,  distin- 
guishes it  from  purring  thrill.  As  a  physical  sign,  the  significance 
of  tactile  pericardial  fremitus  is  neither  more  nor  less  than  that  of  a 
rough  friction-sound. 

It  is  stated  by  Dr.  Walshe  that  when  the  pericardial  sac  contains' 
a  certain  quantity  of  liquid,  the  heart's  impulse  is  sometimes  felt 
after  the  systolic  sound  is  perceived  by  the  ear,  a  distinct  interval 
separating  these  events  which  in  health  occur  synchronously. 


o28  INFLAMMATOKY   AFFECTIONS    OF    THE    HEART. 


Signs  furnished  by  inspection. 

During  the  period  of  liquid  effusion,  if  the  pericardial  sac  be 
considerably  distended,  an  unnatural  prominence  or  arching  of  the 
prcecordial  region  is  sometimes  apparent  to  the  eye,  especially  if  the 
subject  be  young.  This  sign  of  pericardial  effusion  was  first  pointed 
out  by  Louis.  It  is  less  frequent  and  marked  in  cases  of  acute 
pericarditis,  than  when  the  disease  assumes  a  chronic  form,  with  a 
very  large  accumulation  of  liquid.  The  effects  of  great  distension 
of  the  pericardium,  as  determined  by  the  different  methods  of 
exploration,  will  be  noticed  under  the  head  of  chronic  pericarditis. 
Whenever  the  accumulation  is  sufficient  to  occasion  an  obvious 
projection  of  the  prascordia,  the  intercostal  spaces  are,  at  the  same 
time,  widened  and  raised  to  the  level  of  the  ribs.  These  appear- 
ances are  limited  to  a  space  on  the  chest  corresponding  to  that 
which  the  distended  pericardium  occupies ;  and  the  prominence 
may  present,  indistinctly,  an  outline  of  the  pyriform  shape  of  the 
pericardial  sac.  Under  these  circumstances  the  impulse  of  the 
heart  is  rarely  either  seen  or  felt,  a  fact  which  serves  to  distinguish 
prominence  of  the  prascordia  produced  by  pericardial  eff"usion, 
from  that  due  to  enlargement  of  the  heart.  In  the  latter  case,  one 
or  more  points  of  impulse  are  usually  both  seen  and  felt. 

If  the  quantity  of  liquid  be  sufiicient  to  produce  visible  enlarge- 
ment of  the  prtecordia,  the  respiratory  movements  on  the  left  side 
are  somewhat  restrained.  A  disparity  between  the  two  sides,  in 
this  respect,  may  be  obvious.  The  respiratory  movements  of  the 
left  side  may  also  be  restrained  prior  to  the  occurrence  of  effusion, 
in  consequence  of  the  pain  felt  during  inspiration.  Deficient 
respiratory  motion  is  not,  therefore,  alone  a  sign  that  effusion  has 
taken  placQ.  According  to  Dr.  Walshe,  if  the  quantity  of  effusion 
be  moderate,  the  costal  expansion  of  the  left  side  may  even  be 
greater  than  in  health,  in  compensation  for  some  depression  of  the 
diaphragm. 

Inspection  is  sometimes  important  as  a  means  of  determining  the 
situation  of  the  apex-beat  of  the  heart,  in  cases  in  which  this  may 
be  seen  and  not  felt.  Not  infrequently  the  motion  occasioned  by 
the  beat  may  be  discovered  by  the  eye,  when  it  cannot  be  appreci- 
ated by  the  touch. 

Undulatory  movements  in  the  intercostal  spaces  over  the  peri- 
cardium distended  with  liquid,  are  occasionally  observed,  due  to 


MENSURATION    IN    ACUTE    PERICARDITIS.  829 

motion  produced  by  the  heart's  action.  This  sign  possesses  small 
intrinsic  value,  firsts  because  of  its  infrequency,  and  second^  because 
it  is  not  easy  to  distinguish  it  from  the  movements  styled  by  Dr. 
Walshe  quasi  undulatory,  caused  by  the  motions  of  the  heart  itself 
when  much  dilated  and  in  contact  with  the  thoracic  parietes  over 
an  enlarged  area.  The  latter  I  have  often  observed,  while  it  has 
not  occurred  to  me  to  witness  true  undulation  from  liquid.  Occur- 
ring in  concurrence  with  other  signs  denoting  unequivocally 
pericardial  effusion,  it  has  a  positive  significance. 

If  the  quantity  of  liquid  effusion  have  been  sufficient  to  occasion 
a  visible  prominence  of  the  pra3Cordia,  the  removal  of  the  liquid  by 
absorption  may  be  followed  by  an  obvious  prtecordial  depression. 
This  is  sometimes  marked,  and  is  important  as  one  of  the  signs  of 
ancient  pericarditis. 

Signs  furnished  by  mensuration. 

"When  the  priBCordia  is  rendered  abuormally  prominent  by  dis- 
tension of  the  pericardial  sac,  during  the  period  of  effusion,  this  fact 
may  be  determined  by  mensuration.  Diametrical  measurement, 
with  callipers,  is  best  adapted  to  this  object,  for  the  same  reasons  as 
in  cases  of  prominence  due  to  cardiac  enlargement.  The  normal 
deviations  from  equality  of  the  two  sides  of  the  chest,  as  regards 
the  results  of  diametrical  measurement,  are  to  be  borne  in  mind.^ 
The  existence  of  undue  preecordial  prominence  is  determined  by 
the  eye  sufficiently  for  practical  purposes ;  but  the  callipers  may 
be  employed  in  confirmation  of  the  evidence  aflbrded  by  inspection. 
Owing  to  the  rapidity  with  which,  in  certain  cases,  the  liquid,  on 
the  one  hand,  accumulates,  and,  on  the  other  hand,  diminishes,  pvse- 
cordial  prominence  may  be  suddenly  produced  or  increased,  and  as 
suddenly  diminish  or  disappear.  These  variations  may  be  ascer- 
tained with  greater  precision  by  mensuration  than  by  the  eye,  and 
in  recording  cases  which  may  be  reported,  it  is  more  satisfactory  to 
note  the  results  of  measurement,  in  addition  to  the  appearances 
presented  on  inspection. 

SUMMARY  OF  THE  PHYSICAL  SIGXS  OF  ACUTE  PERICARDITIS. 

Percussion. — Enlarged  area  of  prtecordial  dulness ;  the  extent  of 
this  area  greater  in  a  vertical  than  in  a  transverse  direction ;  the 

'   Vide  Chapter  I.  page  69. 


330  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

shape  of  the  area  corresponding  to  the  pyramidal  form  of  the  peri- 
cardial sac  when  distended ;  the  dulness  within  this  area,  and  the 
sense  of  resistance  on  percussion  greater  than  over  the  praecordial 
region  in  health,  or  in  cases  of  enlargement  of  the  heart.  These 
signs  denote  an  abundant  effusion  within  the  pericardial  sac. 
Moderate  or  small  effusion  denoted  by  increased  width  of  the  area 
of  dulness  at  the  lower  and  middle  portions  of  the  praecordial 
region.  The  increase  of  the  area  of  dulness  taking  place  within  a 
few  days  or  hours,  and  progressing  rapidly ;  its  extent  varying  on 
different  days  during  the  course  of  the  disease.  Dulness  from  the 
presence  of  liquid  below  the  point  of  the  apex-beat  of  the  heart. 
Diminution  of  the  area  of  dulness,  with  more  or  less  rapidity,  in 
the  progress  of  the  disease  toward  convalescence,  and  its  final  re- 
duction to  its  normal  limits  when  convalescence  is  established. 

Auscultation. — A  friction-sound  developed,  usually,  soon  after  the 
commencement  of  the  inflammation,  depending,  in  general,  on  the 
exudation  of  lymph;  rarely  wanting  during  the  period  of  the  dis- 
ease which  precedes  that  of  liquid  effusion ;  frequently,  not  invari- 
ably, disappearing  during  the  period  of  effusion  ;  often  returning 
after  the  absorption  of  liquid,  and  sometimes  persisting  after  adhe- 
sion of  the  pericardial  surfaces  has  taken  place.  Intensification  of 
the  heart-sounds  at  the  commencement  of  the  disease,  or  prior  to 
liquid  effusion ;  during  the  period  of  effusion,  both  sounds  weak- 
ened, but  especially  the  first  sound  ;  the  element  of  impulsion  in 
the  first  sound  notably  impaired  or  lost,  and  this  sound,  therefore, 
consisting  of  the  valvular  element  alone,  resembling  the  second 
sound  as  regards  quality  and  duration ;  the  sounds  apparently  dis- 
tant, and  the  apparent  distance  greater  when  the  patient  is  in  some 
positions  than  in  others.  Cessation  of  respiratory  murmur  and 
vocal  resonance,  concurring  with  the  results  of  percussion  in  deter- 
mining the  enlarged  area  of  precordial  dulness  dependent  on  dis- 
tension of  the  pericardial  sac. 

Palpation. — Prior  to  the  period  of  effusion,  the  cardiac  impulse 
abnormally  forcible,  violent,  extending  over  a  larger  space  than  in 
health,  and  sometimes  tumultuous  beating  of  the  heart.  After 
effusion,  the  point  of  apex-beat  raised  and  carried  to  the  left  of  its 
normal  position.  Suppression  of  the  apex-beat,  if  the  quantity  of 
liquid  be  large.  Return  of  the  beat  when  the  liquid  diminishes. 
Vibration  of  the  thoracic  walls  in  the  preecordia  before,  and  some- 


DIAGNOSIS    OF   ACUTE    PEEICARDITIS.  331 

times  after  the  period  of  effusion,  constituting  tactile  friction-fre- 
mitus.  Retardation  of  the  apex-beat  in  some  cases,  after  a  certain 
amount  of  effusion,  so  that  the  first  sound  precedes  it  by  a  distinct 
interval. 

Inspection. — Prominence  or  arching  of  the  precordial  region  in 
some  cases  during  the  period  of  effusion,  if  the  pericardial  sac  be 
distended,  observed  chiefly  in  young  subjects ;  the  prominence  pre- 
senting an  indistinct  outline  of  the  pyriform  shape  of  the  pericardial 
sac.  Restraint  of  the  respiratory  movements  of  the  left  side,  if  the 
quantity  of  liquid  be  large,  and,  also,  prior  to  effusion,  in  some 
cases,  from  pain  felt  in  the  act  of  inspiration.  Undulatory  move- 
ments in  the  intercostal  spaces  over  the  pericardium  distended  with 
liquid,  in  a  very  small  proportion  of  cases.  Depression  of  the 
praecordial  region  in  some  cases,  after  the  absorption  of  liquid.- 

Mensuration. — Prominence  of  the  preecordia,  in  some  cases,  pro- 
duced by  liquid  accumulation  in  the  pericardial  sac,  determined  by 
callipers.  Sudden  development  or  increase  of  prominence,  and  its 
sudden  or  rapid  disappearance. 


Diagnosis  op  Acute  Pericarditis. 

The  diagnosis  of  pericarditis,  until  within  a  few  years,  was  con- 
fessedly difficult  in  all  cases,  and  often  impossible.  So  long  as  the 
discrimination  rested  mainly  on  symptoms,  it  could  rarely  be  made 
with  positiveness.  Laennec  candidly  acknowledged  that  the  disease 
was  not  to  be  recognized,  but  its  existence  only  conjectured.  It 
was  seen,  while  passing  in  review  the  symptomatic  phenomena, 
that  none  of  these  are  distinctive.  As  regards  symptoms  pointing 
to  the  heart,  the  disease  is  not  infrequently  absolutely  latent. 
Moreover,  in  a  certain  proportion  of  cases,  it  is  associated  with 
other  affections  which,  as  it  were,  drown  its  manifestations.  The 
disease  now,  as  heretofore,  is  very  rarely,  if  ever,  ascertained  to 
exist  with  certainty  by  those  who  rely  in  diagnosis  on  symptoms 
alone.  And  since  physical  exploration  is  still  neglected  to  a  great 
extent,  or  imperfectly  understood,  pericarditis  is  habitually  over- 
looked by  a  large  proportion  of  medical  practitioners.  With  the 
aid  of  physical  signs,  the  diagnosis  may  generally  be  made  with 
ease  and  confidence.     These  have  been  sufficiently  considered,  but 


332  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

there  are  certain  sources  of  inadvertcDCj  and  embarrassment  which, 
in  order  to  be  avoided,  should  be  clearly  understood  and  impressed 
upon  the  mind. 

The  disease  is  liable  to  pass  undetected,  because  its  existence  is 
not  suspected,  and  attention  is  not  directed  to  tlie  condition  of  the 
heart.  It  is  important  to  bear  in  mind  the  pathological  relations 
of  the  disease,  in  order  to  be  prepared  to  expect  it,  and  to  be  on 
the  watch  for  the  earliest  evidence  of  its  development.  During  the 
progress  of  acute  rheumatism,  the  prtecordial  region  should  be 
daily  explored  with  reference  to  the  signs  of  pericarditis,  as  well 
as  those  of  endocarditis.  By  so  doing,  a  friction -sound  may  some- 
times be  discovered  when  the  patient  makes  no  complaint  of  pain 
or  other  symptoms  denoting  that  the  pericardial  structure  has 
become  involved.  So,  when  a  patient  is  known  to  be  affected 
with  Bright's  disease,  or  albuminuria,  the  fact  that  inflammation 
of  the  pericardium,  as  well  as  other  serous  structures,  is  apt  to  be 
developed,  is  not  to  be  forgotten,  and  examinations  of  the  chest 
should  not  be  neglected.  In  the  eruptive  and  continued  fevers, 
attention  should  be  directed  to  the  heart,  and,  indeed,  it  is  well  to 
adopt  the  practical  rule  enforced  by  Hope,  which  has  been  already 
mentioned,  viz.,  to  employ  at  least  palpation  habitually  in  all  cases 
of  disease. 

The  coexistence  of  pleuritis,  or  pleuro-pneumonia,  is  liable  to 
lead  the  practitioner  to  overlook  pericarditis,  yirs^,  because,  having 
ascertained  the  existence  of  these  affections,  he  may  attribute  all 
the  symptoms  to  them,  and  not  carry  his  inquiries  farther ;  and, 
second^  because  these  affections  obscure  the  symptoms,  and,  to  some 
extent,  the  signs  of  pericardial  inflammation.  The  diagnosis  of  the 
latter  is,  in  fact,  sometimes  difficult  under  these  circumstances. 
The  heart  should  be  interrogated  as  far  as  possible.  A  friction- 
sound  may  be  discovered  even  when  the  organ  is  displaced  to  the 
right  of  the  sternum.  Symptoms  referable  to  respiration  and  the 
circulation,  out  of  proportion  to  the  pulmonary  affection,  should 
excite  strong  suspicion  of  cardiac  disease.  Liquid  effusion  in  the 
pericardium  when,  at  the  same  time,  there  is  an  abundant  effusion 
in  the  left  pleural  sac,  is  by  no  means  easily  determined;  the 
physical  signs  may  not  be  available  for  a  positive  diagnosis ;  but, 
with  due  attention,  the  pericardial  accumulation  may  sometimes  be 
disconnected  from  the  pleural  by  prominence  of  the  praecordia,  the 
vertical  extent  of  prascordial  dulness,  etc.  An  abundant  effusion 
into  the  right  pleural  sac  does  not  interfere  materially  with  the 


DIAGNOSIS    OF    ACUTE    PERICARDITIS.  833 

signs  of  pericardial  effusion,  and  the  diagnosis  of  the  latter  may  be 
made  with  positiveness.  The  occasional  occurrence  of  a  cardiac 
pleural  friction-sound  is  to  be  recollected  in  connection  with  the 
subject  of  pericarditis  associated  with  pleurisy  seated  in  the  left 
side  of  the  chest.  This  sign  is  a  source  of  fallacy  against  which 
there  is  no  absolute  protection,  and  this  fact  should  lead  the  practi- 
tioner not  to  commit  his  mind  too  unqualifiedly  to  a  diagnosis 
based  exclusively  on  the  existence  of  a  friction-sound. 

I  have  known  acute  pericarditis,  disconnected  from  any  other 
thoracic  affection,  to  be  considered  and  treated  throughout  the  dis- 
ease as  pleurisy ;  but  the  diagnosis  was  based  on  symptoms  alone. 
A  tolerable  knowledge  of  physical  exploration  enables  the  diag- 
nostician to  exclude,  on  the  one  hand,  and,  on  the  other  hand, 
ascertain  the  existence  of  pleurisy  and  pneumonia.  If  the  exami- 
nation of  the  chest  be  limited  to  the  anterior  surface,  the  physical 
signs  of  liquid  within  the  pericardial  sac  might  be  attributed  to 
pleural  effusion  in  the  left  side.  A  proper  examination  of  the 
whole  chest  obviates  liability  to  this  error.  The  signs  of  effusion 
are  limited  to  the  anterior  surface.  Percussion  and  auscultation 
show  the  presence  of  lung  in  the  lower  posterior  portion  of  the 
chest ;  and  it  is  precisely  in  the  latter  situation  that  the  signs  of 
pleuritic  effusion  are  first  manifested  and  most  marked.  This 
error  is  excusable  on  no  other  ground  than  inability  to  employ  the 
means  of  arriving  at  a  correct  diagnosis.  The  occasional  occur- 
rence of  symptoms  referable  to  the  brain  and  spinal  cord,  in 
connection  with  pericarditis,  is  to  be  borne  in  mind.  These  symp- 
toms may  mask  completely  those  pertaining  to  the  cardiac  affec- 
tion, simulating  various  affections  of  the  nervous  system,  viz., 
mania,  apoplexy,  tetanus,  etc.  The  peculiar  characters  which 
serve  to  distinguish  these  cases  are  to  be  kept  in  view,  and  careful 
attention  directed  to  the  heart  in  all  instances  in  which  these 
affections  appear  to  be  present. 

Pericardial  effusion,  occurring  without  inflammation,  has  not  yet 
been  referred  to.  Dropsy  of  the  pericardium,  or  hydro-pericardium, 
rarely  occurs  to  an  extent  sufiQcient  to  occasion  great  distension  of 
the  sac.  It  occurs  very  rarely,  if  ever,  except  in  conjunction  wjth 
effusion  into  other  serous  cavities,  and  the  areolar  tissue,  consti- 
tuting general  dropsy.  The  effusion  into  the  pleural  cavities  is  pro- 
portionately greater  than  into  the  pericardial  cavity.  The  physical 
signs  of  a  certain  quantity  of  purely  serous  or  dropsical  eft\ision 
are,  of  course,  the  same  as  when  the  effusion  is  combined  with 


S34:         INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

lymph,  or,  in  other  words,  inflammatory.  The  pericardial  sac,  in 
proportion  to  its  distension,  occupies  the  same  space,  enlarges  the 
area  of  dulness  to  the  same  extent,  the  latter  presenting  the  same 
pyriform  shape,  etc.,  in  the  two  cases.  The  discrimination,  how- 
ever, rarely  offers  much  real  difficulty.  Liquid  effusion  in  pericar- 
ditis is  generally  preceded  and  accompanied  by  more  or  less  of  the 
symptoms  pointing  to  the  latter  affection,  such  as  pain,  tenderness, 
febrile  movement,  etc.  It  is  preceded  almost  invariably,  and  not 
infrequently  accompanied  by,  a  cardiac  friction-sound.  If  pleuritic 
effusion  be  also  present,  as  determined  by  physical  signs,  it  is  not 
hydro-thorax,  but  due  to  coexisting  inflammation  of  the  pleura; 
and  the  inflammatory  pleuritic  effusion  is  generally  limited  to  one 
side.  On  the  other  hand,  hydro-pericardium  is  an  element  of  gene- 
ral dropsy;  oedema  or  anasarca,  ascites,  and  hydro-thorax,  are  at 
the  same  time  present.  A  friction-sound  is  never  developed.  In 
the  vast  majority  of  cases,  the  patient  is  affected  with  either  Bright's 
disease  or  organic  disease  of  heart,  and  both  affections  may  be 
united.  With  due  attention  to  these  differential  points,  the  two 
kinds  of  effusion,  viz :  dropsical  and  inflammatory,  need  not  be 
confounded. 

In  leaving  the  subject  of  diagnosis,  the  great  importance  of 
becoming  familiar  and  practically  conversant  with  the  physical 
signs  is  to  be  impressed.  With  this  knowledge,  the  practitioner 
will  rarely  be  long  at  a  loss  in  determining  whether  acute  pericar- 
ditis be,  or  be  not  present. 


Prognosis  in  Acute  Pericarditis. 

Acute  pericarditis  is  never  a  trivial,  and  is  often  a  formidable 
affection.  The  fatality,  however,  is  due,  not  so  much  to  the  disease 
itself,  as  to  the  condition  of  the  system,  the  pathological  relations 
of  the  disease,  and  coexisting  affections.  Cases  of  idiopathic  peri- 
carditis are  so  rare  that  that  statistical  data  for  determining  the 
rate  of  mortality  are,  as  yet,  wanting.  Of  106  cases  of  pericarditis 
variously  complicated,  which  were  analyzed  by  Louis,  36  died. 
The  reports  of  different  observers,  as  regards  the  proportion  of 
fatal  cases  in  their  own  experience,  differ  considerably;  and  this 
would  be  expected,  in  view  of  the  great  variation  in  the  tendency 
to  a  fatal  result,  according  to  the  different  circumstances  under 
which  the  disease  is  developed.     Dr.  Hope,  whose  opportunities  for 


PROGNOSIS    IN    ACUTE    PERICARDITIS.  335 

observation  must  have  been  extensive,  makes  the  remarkable  state- 
ment that,  in  ten  years,  he  had  not  lost  a  patient  with  acute  peri- 
carditis, ascribing  this  success  to  the  treatment  pursued.  Yet, 
according  to  the  observations  of  others,  the  disease  is  almost  inva- 
riably fatal,  when  developed  in  certain  pathological  connections. 

In  the  great  majority  of  cases,  pericarditis  occurs  in  connection 
with  either  acute  rheumatism  or  renal  disease.  Occurring  in  con- 
nection with  rheumatism,  it  rarely  proves  fatal.  In  84  cases 
reported  by  Latham,  McLeod,  and  Bouillaud,  there  were  but  8 
deaths ;  and,  in  more  or  less  of  these  fatal  cases,  endocarditis  coex- 
isted. Eheumatic  pericarditis,  thus,  may  be  expected  to  end  in 
recovery,  or,  at  least,  not  to  terminate  fatally  as  an  acute  affection. 
It  is  otherwise  when  the  affection  is  developed  in  connection  with 
Bright's  disease;  a  fatal  result  occurs  almost  invariably.  Death 
takes  place  in  a  large  proportion  of  the  cases  in  which  it  is  asso- 
ciated with  pleurisy  or  pneumonia ;  but,  in  many,  if  not  most  of 
these  cases,  it  is  probable  that  the  kidneys  are  the  seat  of  disease. 
The  proportion  of  fatal  cases  of  pericarditis  developed  in  connec- 
tion with  the  eruptive  and  continued  fevers,  pyaemia,  etc.,  must  be 
immensely  large ;  but  statistical  data  are  wanting  to  determine  the 
ratio  with  any  approximation  to  exactness.  The  disease  is  gene- 
rally fatal  when  associated  with  marked  disorder  of  the  nervous 
system,  giving  rise  to  mania,  tetanus,  chorea,  etc. 

As  regards  the  fatality  in  my  own  experience,  the  following  are 
the  results  of  an  analysis  of  19  recorded  cases,  with  reference  to 
this  subject :  Of  the  19  cases,  death  occurred  in  12,  and  in  7  the 
disease  ended  in  recovery.  Of  the  12  fatal  cases,  renal  disease,  with 
albuminuria,  was  ascertained  to  exist  in  3;  pleuritis  coexisted  in 
5;  pneumonitis  in  2;  tuberculosis  of  the  lungs  in  3;  maniacal  deli- 
rium in  2;  and  in  1  case  no  important  complication  was  ascertained. 
In  the  case  last  mentioned,  the  disease  did  not  present  any  alarming 
symptoms,  but  death  occurred  suddenly,  apparently  from  syncope, 
while  the  patient  was  at  stool.  The  pericardial  sac  contained  a  pint 
of  turbid  serum.  The  heart  presented  two  patches  of  lymph,  one 
of  the  size  of  a  dollar,  and  the  other  of  the  size  of  a  shilling  piece. 
The  pulmonary  organs  were  free  from  recent  disease,  but  old  pleu- 
ritic adhesions  existed  on  both  sides,  and  they  were  universal  on 
the  right  side.  The  chest  was  alone  examined.  Of  the  7  cases 
ending  in  recovery,  in  4  the  disease  was  developed  in  connection 
with  rheumatism ;  in  1  case  it  was  apparently  idiopathic,  and  was 


336  INFLAMMATORY   AFFECTIONS    OF    THE    HEART, 

associated  with  maniacal  delirium  ;  in  1  case  pneumonia  coexisted ; 
and  in  1  case  it  followed  albuminuria,  succeeding  scarlatina.'     • 

The  duration  of  the  disease  is  variable.  It  may  prove  rapidly 
fatal.  In  a  case  reported  by  Andral,  death  occurred  in  twenty- 
seven  hours  ;  but  it  is  extremely  rare  that  it  runs  with  this  rapidity 
to  a  fatal  issue.  .  It  continues,  usually,  from  one  to  two  weeks.  If 
it  do  not  prove  fatal  within  this  period,  it  ends  either  in  recovery 
or  in  the  chronic  form  of  the  disease.  The  latter  will  presently  be 
considered  under  a  distinct  head. 

The  termination,  in  favorable  cases,  is  usually  in  more  or  less 
adhesion  of  the  pericardial  surfaces.  It  may  fairly  be  doubted 
whether  the  exuded  products  are  ever  completely  removed  by 
absorption,  leaving  the  surfaces  of  the  membrane  unattached,  and 
presenting  no  traces  of  the  disease.  Some,  however,  have  contended 
that  this  complete  resolution  occasionally  takes  place.  As  a  rule, 
certainly,  permanent  effects  are  left  here,  as  after  recovery  from 
inflammation  affecting  other  serous  structures,  consisting  of  adhe- 
sions by  means  of  newly  organized  tissue  which  becomes  more  and 
more  firm  with  age.  Adhesion  may  take  place  over  the  entire 
surfaces  of  the  membrane,  the  pericardial  sac  being  obliterated, 
like  that  of  the  tunica  vaginalis  after  the  radical  cure  of  hydrocele. 
In  fact  this  appears  to  be  the  rule.  Of  70  cases  of  pericardial 
adhesions  analyzed  by  Louis,  they  were  general  in  60,  and  partial  in 
10  ;  and  of  86  cases  of  old  adhesions  analyzed  by  Dr.  Chambers,  51 
were  universal,  4  nearly  so,  and  29  partial.^  The  subject  of  peri- 
cardial adhesions,  with  reference  to  their  remote  eflfects  upon  the 
heart,  and  the  diagnosis,  will  be  noticed  separately,  after  chronic 
pericarditis  has  been  considered.  The  most  favorable  termination 
of  acute  pericarditis,  next  to  complete  resolution  (the  occurrence  of 
which  is  doubtful),  is  the  formation  of  circumscribed  white  patches, 
consisting  of  thin  layers  of  dense  lymph,  firmly  agglutinated  to  the 
membrane,  becoming  nearly  as  smooth  and  polished  as  the  mem- 
brane itself.  These  white  patches  {rnaculce  albidce),  as  an  effect  of 
circumscribed  or  partial  pericarditis,  have  been  already  noticed. 
It  is  possible  that  patches  similar  to  these  are,  in  some  cases,  the 

'  It  is  proper  to  state  that  the  foregoing  collection  of  cases  does  not  include  aU 
that  have  fallen  under  my  observation,  but  only  those  of  which  I  find  notes  among 
my  clinical  records.  It  probably  embraces  the  greater  proportion  of  fatal  cases 
which  I  have  observed,  while,  of  a  considerable  number  of  cases  of  rheumatic  peri- 
carditis not  ending  fatally,  I  have  not  preserved  notes. 

2  Decennium  Pathologicum.      Vide  Belliugham,  op.  cit.,  Part  II.  p.  309. 


MODE    OF    DYING    IN   ACUTE    PERICARDITIS.  337 

only  permaDent  effects  of  acute,  general  pericarditis ;  but  this  must 
be  considered  as  doubtful. 

The  mode  of  dying,  in  cases  of  acute  pericarditis,  is  not  uniform. 
Wlieu  life  is  destroyed  by  the  disease  jjer  se,  the  result  is  imme- 
diately due  either  to  sudden  syncope  or  gradual  asthenia.  The 
arrest  of  the  circulation  is  the  immediate  cause  of  death;  and  this 
is  owing  to  paralysis  of  the  heart,  usually  from  the  combined 
influence  of  the  mechanical  pressure  of  liquid  effusion,  and  the 
proximity  of  the  inflamed  membrane  to  the  muscular  fibres  of  the 
organ.  In  the  latter  respect,  the  influence  is  analogous  to  that  of 
inflammation  of  the  peritoneum  on  the  muscular  coat  of  the 
intestines.  It  is  important  to  keep  in  view  this  twofold  influence 
in  producing  a  tendency  to  a  fatal  result,  since  it  should  govern,  to 
a  considerable  extent,  the  indications  for  treatment.  But  in  the 
great  majority  of  fatal  cases  of  pericarditis,  concomitant  affections 
contribute,  in  no  small  degree,  to  the  fatal  result,  and  the  mode  of 
dying  will,  in  a  measure,  be  determined  by  these.  For  example, 
when  the  disease  is  associated  with  pleurisy  or  pneumonia, 
asphyxia  is  involved  as  an  immediate  cause  of  death.  Again, 
when  developed  in  the  course  of  Bright's  disease,  the  powers  of  the 
system  being  exhausted  by  the  latter,  the  tendency  to  death  may 
be  by  slow  asthenia;  or  coma  may  be  induced  as  an  effect  of 
uraemia,  not  of  the  cardiac  affection.  An  example  of  the  latter  has 
fallen  under  my  observation.  Coma  precedes  death  in  the  cases  in 
which  pericarditis  simulates  various  affections  of  the  brain  and 
spinal  cord.  A  liability  to  sudden  death  from  syncope,  during  the 
period  of  effusion,  must  not  be  overlooked.  This  may  occur  after 
some  unusual  muscular  exertion,  or  a  sudden  change  from  a  hori- 
zontal to  a  vertical  position.  An  instance  in  which  death  occurred 
suddenly  and  quite  unexpectedly,  in  a  case  under  my  observation, 
has  been  referred  to,  fatal  syncope  being  induced  by  getting  out  of 
bed  and  going  to  stool.  The  inflammation  in  this  case,  as  shown 
by  the  appearances  after  death,  as  well  as  the  symptoms  during 
life,  was  not  intense,  and  the  pericardial  sac  did  not  contain  more 
than  a  pint  of  liquid  efl'usion. 


Treatment  of  Acute  Pericarditis. 

In  the  treatment  of  most  acute  inflammations,  the  general  symp- 
toms, the  condition  of  the  system,  the  pathological  relations  of  the 
22 


338  INFLAMMATOEY    AFFECTIONS    OF    THE    HEART. 

disease,  etc.,  arc  more  immediately  involved  in  therapeutical  indi- 
cations, than  the  local  processes  which  constitute  the  inflammatory 
affection.  The  treatment  of  acute  pericarditis  does  not  form  an 
exception  to  the  rule  embodied  in  this  statement.  Acute  pericar- 
ditis is  developed  under  circumstances  so  widely  different  in  dif- 
ferent cases,  that,  assuming  the  local  characters  of  the  inflammation 
to  be  identical,  the  indications  for  treatment  are  by  no  means 
uniform.  Measures  useful  in  some  cases  are  pernicious  in  other 
cases.  Methods  of  management  diametrically  opposite,  are  indi- 
cated by  different  circumstances  connected  with  the  disease.  It 
follows  that  the  treatment  cannot  be  reduced  to  a  fixed  formula 
applicable  to  all  cases.  Here,  as  in  other  affections,  the  significant 
saying  of  Chomel  is  pertinent,  viz.,  the  disease  is  not  to  be  treated 
so  much  as  the  patient  affected  with  the  disease.  In  the  majority 
of  cases,  pericarditis  occurs  in  connection  with  acute  rheumatism. 
Exclusive  of  its  occurrence  in  this  pathological  connection,  it  is 
most  apt  to  become  developed  in  the  course  of  albuminuria  or 
Bright's  disease.  The  local  inflammation,  in  all  essential  points,  so 
far  as  these  are  appreciable,  may  be  the  same  in  these  two  classes 
of  cases,  but  in  other  respects,  the  difference  is  very  great.  Eheu- 
matic  pericarditis  involves  small  immediate  danger  to  life,  although 
its  remote  evils  may  be  serious.  In  renal  pericarditis  (if  this  ex- 
pression may  be  used)  the  immediate  danger  to  life  is  imminent. 
The  chances  of  recovery  in  the  latter  are  less  than  the  chances  of 
death  in  the  former.  Both  forms  of  the  disease  are  dependent  on 
special  diathetic  or  constitutional  conditions  which  are  essentially 
dissimilar.  The  active  rheumatic  diathesis  is  acute,  ti'ansient  in 
duration,  affecting  the  young;  the  ur£emic  condition  is  incident  to 
a  chronic,  persistent  affection,  and  occurs  at  a  later  period  in  life. 
The  ability  to  bear  up  under  any  grave  local  disease,  and  to  support 
potent  remedial  agencies,  is  as  different  as  are  the  pathological 
relations  of  the  disease  in  these  two  forms.  In  addition  to  these,  a 
variety  of  modifying  circumstances  are  present  in  different  cases  of 
pericarditis,  not  peculiar  to  this  disease,  but  affecting  the  symptoms, 
the  powers  of  the  system,  etc.,  so  as  to  influence,  in  various  and 
opposite  modes,  the  leading  objects  of  treatment.  It  is  not  to  be 
inferred  from  these  remarks  that,  in  the  treatment  of  pericarditis, 
great  importance  does  not  belong  to  the  local  morbid  conditions. 
It  is  by  means  of  the  vital  and  mechanical  effects  of  the  latter  that 
the  disease  proves  destructive  to  life.  The  objects  of  treatment 
relate  to  the  local  morbid   conditions ;    but  in  promoting  these 


I 


TREATMENT    OF    ACUTE    PERICARDITIS.  339 

objects,  the  indications  are  in  a  great  measure  derived  from  the 
circumstances  just  referred  to. 

It  is  obvious  that  the  first  and  most  important  object  of  treat- 
ment, were  it  attainable,  would  be  the  arrest  of  the  inflammation. 
But  we  are  not  warranted  in  assuming  this  as  an  object  to  be 
effected  by  therapeutical  measures.  With  our  present  knowledge, 
we  cannot ^aj  that  certain  methods  of  management  will  cut  short 
the  inflammatory  processes  here,  more  than  in  other  situations. 
Potent  means  adopted  for  that  end,  not  only  prove  ineffectual,  but 
involve  the  risk  of  doing  harm  rather  than  good.  To  abridge  the 
duration  of  the  inflammation  is  an  object,  the  importance  of  which 
is  sufficiently  obvious.  How  far  this  object  is  attainable,  must  be 
considered  as  doubtful,  but  we  are  perhaps  justified  in  regarding  it 
as  an  end  to  which  therapeutical  measures  are  to  be  directed.  To 
endeavor  to  diminish  the  intensity  of  the  inflammation,  is  a  legiti- 
mate object  of  treatment.  The  products  of  inflammation,  solid  and 
liquid,  in  this  situation,  involve  serious  evils  and  danger.  It  is  an 
object  of  treatment  to  endeavor  to  lessen  these,  and  to  promote 
their  removal.  To  aid  in  maintaining  the  vigor  of  the  heart  under 
the  effects  of  the  disease,  is  an  important  end  to  be  kept  in  view 
in  the  treatment.  I  shall  proceed  to  notice  the  more  important  of 
the  therapeutical  measures  which  are  supposed  to  promote  the 
objects  or  ends  of  treatment  in  acute  pericarditis.  These  may  be 
arranged  under  the  following  heads :  Bloodletting,  mercurialization, 
sedatives,  revulsives  or  counter-irritants,  opium,  stimulants,  and 
eliminatives. 

Bloodletting. — The  two  authors  whose  labors  have  contributed 
most  to  the  recent  progress  made  in  the  knowledge  of  diseases  of 
the  heart,  viz.,  Bouillaud  and  Hope,  both  advocate  strongly  the  im- 
portance of  bloodletting  in  cases  of  acute  pericarditis.  Bouillaud 
employs,  in  this  disease,  his  method  of  copious  bleedings,  repeated 
once  or  oftener  daily  for  four  or  five  successive  days  {coup  sur  coup\ 
with  which  medical  readers  are  familiar.  Hope's  method  differs 
from  that  of  Bouillaud  in  the  employment  of  bloodletting  only  at 
the  outset,  and  carrying  it  to  the  extent  of  producing  a  prompt  and 
decided  impression  on  the  heart's  action.  Each  advocates  the  de- 
traction of  blood  both  by  venesection,  and,  locally,  by  leeching  or 
cupping.  Writers  of  a  more  recent  date  (Stokes,  Todd,  and  others) 
distrust  the  ef&cacy  of  this  remedy,  and  attribute  to  it  in  many 
cases  unfavorable  effects.     Without  entering  into  a  discussion  of 


840  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

the  subject  of  bloodletting,  which  would  here  be  out  of  place,  it  is 
sufficient  to  say  that,  with  certain  cjualifications,  the  general  prin- 
ciples which  should  regulate  the  employment  of  this  potent  remedy 
in  other  acute  inflammations,  are  applicable  to  the  treatment  of 
acute  pericarditis.  Its  indiscriminate  use  in  this,  as  in  other  inflam- 
mations, cannot  but  be  productive  of  much  harm,  whereas,  judi- 
ciously employed,  it  may  not  infrequently  do  good.  Tke  practical 
Cjuestions  are,  under  what  circumstances  is  bloodletting  indicated, 
and  what  are  the  contra-indications  to  its  use?  A  person  in  fair 
health  and  vigor,  attacked  with  acute  pericarditis,  as  an  idiopathic 
or  a  rheumatic  affection,  is  a  proper  subject  for  bloodletting  at  the 
onset  of  the  disease.  Eesorted  to  under  these  circumstances,  it  will 
not  cut  short  the  disease,  and  perhaps  not  abridge  its  duration ; 
but  it  may  contribute  to  diminish  the  intensity  of  the  inflammation, 
and  thus,  without  risk  of  injury,  not  only  afford  immediate  relief, 
but  lessen  the  evils  and  the  danger,  proximate  and  remote,  which 
are  involved  in  the  disease.  The  amount  of  blood  to  be  detracted, 
must  be  determined  by  the  constitution,  habits,  etc.,  of  the  patient, 
the  symptoms  referable  to  the  circulation,  and  the  immediate  effects 
upon  the  vascular  system.  Whether  the  bloodletting  shall  be  gene- 
ral or  local,  or  both,  is  to  be  determined  mainly  by  the  quantity  of 
blood  which  it  is  deemed  desirable  to  withdraw,  and  the  compara- 
tive convenience  of  venesection  and  cupping  or  leeching.  It  is 
difficult  to  conceive  of  any  important  difference  between  these  dif- 
ferent methods,  as  regards  their  effect  on  the  disease,  except  so  far 
as  concerns  the  rapidity  with  which  the  blood  is  removed,  and  the 
amount  detracted.  The  benefit  derived  from  bloodletting  will  be 
evidenced  by  relief  of  pain,  greater  freedom  of  breathing,  diminished 
force  and  greater  regularity  of  the  heart's  action.  These,  then,  are 
the  circumstances  which  may  indicate  bloodletting,  viz.,  the  disease 
idiopathic,  or  rheumatic;  occurring  in  a  patient  previously  healthy 
and  tolerably  vigorous ;  the  inflammation  recently  developed,  or, 
in  other  words,  the  disease  being  in  its  first  period,  and,  to  these  is 
to  be  added,  a  certain  degree  of  intensity  or  acuteness  of  the  inflam- 
mation, as  manifested  by  pain,  development  of  the  pulse,  etc.  The 
indications  based  on  these  circumstances  are  present  in  a  certain 
proportion  of  cases  of  pericarditis.  The  contra-indications,  how- 
ever, are  present  in  a  larger  proportion  of  cases.  Pericarditis  oc- 
curring in  connection  with  Bright's  disease,  rarely,  if  ever,  calls 
for  bloodletting.  The  anaemic  condition  incident  to  that  disease, 
constitutes  a  contra-indication.     Ana3mia  from  other  causes,  weak- 


TREATMENT    OF    ACUTE    PERICARDITIS.  341 

ness  or  deterioration  of  the  constitution  from  previous  or  coexist- 
ing disease,  habits  of  intemperance,  etc.,  are  contra-indicating 
circumstances.  Bloodletting  should  not  be  practised  after  much 
liquid  effusion  has  taken  place;  it  is  contra-indicated  by  the  risk  of 
unduly  weakening  the  heart  under  these  circumstances.  It  is  not 
indicated  when  the  symptoms  denote  only  moderate  acuteness  or 
intensity  of  the  inflammation. 

In  conclusion,  as  regards  bloodletting,  the  mischief  occasioned 
by  its  injudicious  employment  may  greatly  exceed  the  benefit  ever 
to  be  expected  from  its  judicious  use.  This  only  shows  the  great 
importance  of  discrimination ;  and  the  remark  is  alike  applicable 
to  this  remedy  in  the  treatment  of  other  inflammations.  But  the 
injudicious  detraction  of  blood  in  pericarditis  involves  a  peculiar 
source  of  danger.  It  has  been  seen  that  this  disease  destroys  life 
by  compression  and  paralysis  of  the  heart.  Any  remedy  which 
tends  directly  to  weaken  this  organ,  when  weakness  is  the  morbid 
condition  to  be  most  apprehended,  can  hardly  fail,  in  proportion  to 
the  effect  produced,  to  influence  unfavorably  the  progress  of  the 
disease.  This  consideration  cannot  be  too  strongly  impressed. 
Here,  as  in  other  affections,  the  attention  of  the  practitioner  must 
not  be  directed  exclusively  to  the  good  which  it  is  hoped  may  be 
effected  by  a  potent  remedy.  The  risk  of  harm  is  to  be  carefully 
weighed,  and,  with  reference  to  the  latter,  the  mode  in  which  the 
disease  tends  to  a  fatal  result  is  especially  to  be  considered. 

Mercurialization. — Mercury,  given  with  the  view  of  producing  its 
special  effects,  or  mercurialization,  is  regarded,  especially  by  most 
British  writers,  as  highly  essential  in  the  treatment  of  ^cute  peri- 
carditis. It  is  supposed  to  exert  a  favorable  influence  on  the  pro- 
gress of  the  disease  by  lessening  the  exudation  of  lymph  and 
promoting  the  resorption  of  the  inflammatory  products.  "With 
reference  more  particularly  to  the  first  of  these  ends,  it  is  deemed 
important  to  induce  mercurialization  as  early  in  the  disease  as  pos- 
sible. Calomel  may  be  given  for  this  purpose,  either  in  fractional 
doses,  repeated  at  short  intervals,  or  in  large  doses,  combined  with 
sufficient  opium  to  prevent  its  purgative  action ;  and,  in  order  to 
effect  this  object  as  speedily  as  possible,  some  writers  advise,  in 
addition,  inunction  with  mercurial  ointment,  or  the  mercurial  va- 
por-bath. Bouillaud,  and  most  French  writers,  on  the  other  hand, 
appear  to  attach  little  importance,  or  none  whatever,  to  the  special 
effects  of  mercury  in  this  disease.     It  is  claimed  by  some  British 


342  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

writers  tliat  the  disease  is  managed  mucli  more  successfully  in 
Great  Britain  than  in  France,  and  that  this  greater  success  is  owing, 
in  a  great  measure,  to  the  free  use  of  mercury.  The  testimony, 
however,  of  some  i3ritish  observers,  on  this  score,  is  unfavorable 
to  the  efficacy  of  the  remedy.  Dr.  Taylor,  for  example,  found  that 
in  a  considerable  number  of  cases  in  which  salivation  was  induced, 
a  speedy  abatement  of  the  disease  did  not  take  place,  and  in  several 
instances  it  was  increased  in  extent  and  intensity.^  With  reference 
to  this  and  other  therapeutical  questions,  satisfactory  statistical  data 
are  as  yet  wanting.  Nor  is  much  to  be  expected  from  statistics  in 
determining  the  value  of  remedial  agencies  in  a  disease  which  va- 
ries so  greatly  in  severity  and  danger,  according  to  its  pathological 
relations  and  other  circumstances,  and  which  is  not  sufficiently 
common  for  a  large  number  of  cases  to  fall  under  the  observation 
of  any  one  practitioner.  Moreover,  here,  as  with  regard  to  many 
other  acute  affections,  the  natural  tendency  of  the  disease,  uninflu- 
enced by  remedial  measures,  is  not  fully  ascertained,  and  it  must 
be  long  ere  the  data  for  this  knowledge  can  be  acquired. 

Mercury  is  advocated  in  pericarditis  on  precisely  the  same 
grounds  as  in  other  inflammations — for  example,  pleurisy  or  pneu- 
monia. But  confidence  in  the  utility  of  the  remedy  in  the  latter 
affections  has  of  late  years  greatly  diminished,  and  at  the  present 
moment,  many  judicious  practitioners  do  not  deem  its  special  effects 
in  the  treatment  of  these  affections  either  demanded  or  desirable. 
Distrust  of  the  supposed  influence  of  mercurialization  upon  the  pro- 
cess of  exudation  and  the  removal  of  morbid  products,  is  evidently 
gaining  ground.  Even  iritis,  the  affection  which  has  been  hereto- 
fore regarded  as  affording  convincing  oCular  proof  of  the  power  of 
mercury  in  effecting  the  removal  of  lymph,  has  been  shown  by  Dr. 
Williams,  of  Boston,  to  progress  quite  as  favorably,  if  not  more  so, 
when  this  remedy  is  withheld.^  Moreover,  as  regards  the  influence 
of  mercurialization  on  pericarditis,  the  fact  that,  in  the  course  of 
acute  rheumatism,,  the  disease  has  been  repeatedly  observed  to 
become  developed  during  salivation,  militates  against  the  applica- 
bility of  mercury  as  a  remedy.     Dr.  Fuller  gives  several  instances 

'  Bellingliam,  op.  cit.,  pt.  ii.  p.  326. 

'  On  the  Treatment  of  Iritis  without  Mercury.  By  Henry  W.  Williams,  M.  D. 
Reprinted  from  the  Boston  Medical  and  Surgical  Journal,  1856.  The  conclusions 
in  this  paper  are  based  on  the  results  of  the  treatment  of  sixty-four  cases  of  iritis 
without  mercury.  These  results  are  of  great  interest  and  value  in  their  bearing 
on  the  non-mercurial  treatment  of  inflammations  generally. 


TREATMENT    OF    ACUTE    PERICARDITIS.  .  343 

in  illustration  of  this  fact,  and  examples  have  fallen  under  my  own 
observation.  Confessing  doubt  concerning  the  propriety  of  mer- 
curializing patients  affected  with  pericarditis,  I  am  not  prepared  to 
deny,  in  Mo,  the  importance  of  this  method  of  treatment,  inasmuch 
as  the  inconvenience  and  evils  incident  to  moderate  salivation,  in 
many  cases  of  this  disease,  are  hardly  deserving  consideration, 
provided  the  remedy  be  entitled  to  a  tithe  of  the  value  which  is 
claimed  for  it. 

Assuming  a  certain  amount  of  efficacy  in  behalf  of  mercurializa- 
tion,  it  is  not  adapted  to  all  cases.  It  is  allowable  chiefly  in  cases 
of  idiopathic  and  rheumatic  pericarditis.  It  is  contra-indicated  by 
the  coexistence  of  Bright's  disease,  and  is  not  appropriate  whenever 
pericardial  inflammation  is  developed  in  connection  with  ancemia 
or  a  broken  constitution.  The  importance  of  this  discrimination  is 
conceded  by  those  who  advocate  strongly  the  importance  of  the 
remedy. 

Sedatives. — Under  this  head,  I  refer  to  certain  drugs  which  de- 
press the  powers  of  the  system,  and  particularly  the  action  of  the 
heart,  such  as  antimony,  digitalis,  the  veratrum  viride,  etc.  The 
excitement  and  disorder  of  the  circulation  often  incident  to  the 
first  period  of  pericarditis  might  perhaps  suggest  the  employment 
of  remedies  of  this  class.  In  general,  they  are  not  appropriate. 
Employed  during  the  period  of  effusion,  especially  if  the  quantity 
of  liquid  be  large,  they  are  dangerous  remedies  if  carried  to  the 
extent  of  weakening  or  retarding  considerably  the  movements  of 
the  heart.  They  are  only  admissible  before  and  after  the  period  of 
effusion,  and  are  rarely  indicated  at  any  time  during  the  career  of 
the  disease. 

Revulsives  or  Counter-irritants. — These  are  useful  for  the  same 
reasons,  and  probably  to  the  same  extent,  as  in  the  treatment  of 
inflammation  affecting  analogous  structures,  for  example,  pleuris}'- ; 
and  the  general  principles  which  should  govern  their  employment 
are  the  same.  During  the  early  and  most  acute  period  of  the 
disease,  blisters  and  other  active  modes  of  counter-irritation  are ' 
inadmissible.  Eevulsive  measures,  such  as  sinapisms,  fomentations, 
and  foot-baths,  are,  to  a  certain  extent,  useful  during  this  period. 
Vesication  over  the  pr^ecordia  when  the  pericardial  sac  is  distended, 
and  the  intensity  of  the  inflammation  has  abated,  probably  hastens 
absorption,  as  it  apparently  does  in  cases  of  pleurisy  with  effusion. 


344  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

But  there  is  this  objection  to  the  application  of  blisters  directly 
over  the  heart:  they  interrupt  daily  physical  exploration  in  order 
to  determine  the  quantity  of  liquid  effusion,  etc.  After  the  absorp- 
tion of  the  liquid,  it  is  possible  that  moderate  counter-irritation, 
maintained  by  small  blisters,  an  issue,  or  pustulation  with  croton 
oil,  may  serve  to  bring  the  inflammation  speedily  and  completely 
to  an  end,  preventing  a  termination  in  the  chronic  form  of  the 
disease.  The  pathological  relations  of  the  pericarditis  and  the 
state  of  the  sj^stem  are  to  be  taken  into  account  in  deciding  on  the 
propriety  of  counter-irritation  and  the  extent  to  which  it  is  to  be 
carried.  The  practical  question  is,  Will  the  probability  of  its 
superseding  the  disease  warrant  the  risk  of  adding  to  the  irritation 
and  exhaustion  of  the  disease  if  revulsion  be  not  effected  ?  This  is 
a  therapeutical  problem  which  the  practitioner  cannot  be  expected 
to  determine  positively  in  individual  cases,  except  by  employing 
experimentally  counter-irritant  measures. 

Opium. — The  utility  of  opium  is  generally  admitted.  But  there 
are  grounds  for  the  belief  that  the  value  of  this  remedy  in  the 
treatment  of  pericarditis  has  not  been  hitherto,  and  is  not  now, 
generally  appreciated.  In  analogous  local  inflammations — peri- 
tonitis, pleuritis,  pneumonia,  and  perhaps  may  be  added  meningitis 
— opium  exerts  often  a  remarkable  influence,  not  merely  as  a 
palliative,  but  as  a  remedial  agent.  It  relieves  pain  and  quiets 
functional  excitement;  but,  more  than  this,  it  appears  to  control,  to 
a  considerable  extent,  the  processes  of  inflammation,  abating  its 
intensity,  abridging  its  duration,  and  contributing  to  a  favorable 
termination.  To  secure  its  full  potency,  it  must  hold  a  leading,  not 
a  subordinate  place  in  the  management;  and  clinical  experience 
shows  that  in  these  affections  there  is  often  a  remarkable  tolerance 
of  the  remedy,  so  that,  to  produce  a  proper  effect,  large  doses  are 
frequently  requisite.  Analogy  would  lead  to  the  expectation  of  a 
similar  remedial  power  in  cases  of  acute  pericarditis.  It  remains 
to  accumulate  a  sufficient  number  of  cases  in  the  treatment  of 
which  reliance  has  been  chiefly  placed  on  the  free  use  of  opium,  in 
order  to  confirm  the  correctness  of  this  inferential  reasoning.  It 
will  be  understood  that  these  remarks  have  reference  to  opium  as 
a  prominent  remedy  in  the  treatment  of  pericarditis.  As  a  sub- 
sidiary remedy,  its  value  is  already  sufiicientlj'-  attested  by  expe- 
rience. 

The  use  of  opium  has  this  advantage  over  other  measures,  viz., 


TREATMENT    OF    ACUTE    PEEICAEDITIS.  345 

it  is  not  positively  contra-indicated  by  any  of  the  various  and 
opposite  circumstances  associated  with  the  disease.  If  it  be  appro- 
priate in  rheumatic  pericarditis,  it  is  equally  so  when  pericardial 
inflammation  is  developed  in  the  course  of  Bright's  disease,  or  in 
other  pathological  relations.  If  it  be  not  efficacious,  it  is  not 
mischievous,  except  so  far  as  it  may  supplant  other  measures  and 
involve  loss  of  time.  It  admits  of  being  employed  tentatively 
without  incurring  much,  if  any,  risk  of  doing  harm,  even  by  delay. 
Its  potency  for  evil  is  not  proportionate  to  its  potency  for  good, 
and  this  cannot  be  said  of  most  potent  remedial  agencies. 

The  periods  of  the  disease  most  favorable  for  the  beneficial 
influence  of  opium  are  the  period  anterior  and  that  subsequent  to 
liquid  effusion.  It  is,  however,  by  no  means  certain  that  the 
remedy  affects  unfavorably  absorption  of  the  effused  liquid.  I 
have  known  an  abundant  pleural  effusion,  in  connection  with 
pleuro-pneumonia,  to  disappear  rapidly  when  no  other  remedy  was 
employed. 

StimuJants. — In  all  inflammatory  affections,  diffusible  or  alcoholic 
stimulants  form  an  essential  part  of  the  treatment,  whenever  measures 
to  sustain  the  power  of  the  system,  and  obviate  the  tendency  to 
death  by  asthenia,  are  indicated.  Pericarditis  is  by  no  means 
exempt  from  these  indications ;  on  the  contrary,  since  the  imme- 
diate danger  from  the  disease  chiefly  arises  from  weakness  of  the 
heart,  sustaining  measures  would  seem  to  be  called  for  earlier  and 
more  imperatively  than  in  most  local  inflammations.  As  remarked 
by  Dr.  Stokes,  little  is  said  by  authors  on  the  use  of  stimulants  in 
pericarditis.  This  distinguished  author  adds :  "  I  am  convinced 
that  cases  are  often  lost  from  want  of  stimulation  at  the  proper  time ; 
and  it  is  certain  that,  in  every  case  of  dangerous  pericarditis,  after 
the  first  violence  of  the  disease  has  been  subdued,  we  should  be 
anxiously  on  the  watch  for  the  moment  when  the  weakened  heart 
requires  to  be  supported  and  invigorated."  In  the  treatment  of 
inflammatory  affections  generally,  timidity  in  the  use  of  stimulants 
is  apt  to  proceed  from  the  attention  of  the  practitioner  being  too 
exclusively  directed  to  the  local  morbid  processes,  the  state  of  the 
system  being  overlooked,  or  not  sufficiently  regarded.  Measures 
designed  to  abate  the  intensity  of  inflammation,  and  to  control  its 
processes,  pertain,  for  the  most  part,  to  an  early  period  in  the  dis- 
ease. After  a  certain  time,  all. the  immediate  local  results  of  inflam- 
mation, which  may  be  expected  to  occur,  have  already  taken  place. 


346         INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

and  the  general  object  of  treatment,  then,  is  to  maintain  the  forces 
of  life  through  the  processes  of  restoration.  The  physician,  under 
these  circumstances,  is  to  regard  the  patient  more  than  the  disease, 
in  looking  for  therapeutical  indications.  Alcoholic  stimulants,  given 
to  support  the  flagging  powers  of  life,  do  not  excite,  as  in  health, 
but,  associated  with  nutriment,  they  sustain  the  vital  forces,  keeping 
the  patient  alive,  in  some  cases  in  which  death  from  asthenia  is 
threatened,  until  the  period  of  danger  is  passed.  They  are  to  be  given 
with  a  freedom  proportionate  to  the  indications  and  the  apparent 
effects.  These  general  views,  as  applied  to  local  inflammations 
indiscriminately,  seem  to  me  to  possess  very  great  practical  import- 
ance. With  regard  to  pericarditis,  it  is  only  necessary  to  add  that 
they  are  at  least  as  applicable  to  this  as  to  any  other  inflammatory 
affection. 

Eliminaiives. — The  propriety  of  eliminative  remedies  in  pericar- 
ditis rests  on  the  pathological  relations  of  the  disease  in  certain 
cases.  As  developed  in  connection  with  rheumatism  and  Bright's 
disease,  the  pathology  is  supposed  to  involve  a  materies  morhi,  the 
removal  of  which  from  the  system  may,  perhaps,  be  promoted  by 
remedies  employed  for  that  purpose.  Thus,  in  rheumatic  pericar- 
ditis, the  question  arises  whether  those  remedies  supposed  to  be 
efficacious  as  eliminative  agents  in  rheumatism,  may  not  diminish 
or  expel  a  cause  which  serves  to  perpetuate  the  cardiac  inflamma- 
tion. It  is  obvious  that  remedies  of  this  class,  if  they  possess  any 
efficacy,  are  more  indicated  as  prophylactic  than  curative  agents ; 
and,  with  reference  to  the  prevention  of  pericarditis  in  rheumatism, 
clinical  observation  shows  that  cardiac  inflammation  may  become 
developed  under  any  of  the  various  methods  of  treatment  which 
are  pursued  in  the  latter  affection.  Without  discussing  this  im- 
portant practical  subject,  I  will  simply  say  that  we  are  hardly  war- 
ranted in  asserting  that  any  one  or  more  remedies  can  be  relied 
upon  to  prevent  the  development  of  pericarditis  in  rheumatism; 
but,  on  the  other  hand,  it  is  by  no  means  improbable  that  certain 
measures  may  exert  an  influence  more  or  less  prophylactic.  Of  the 
remedies  which  have  been  supposed  to  possess  a  controlling  power 
over  acute  rheumatism,  by  means  of  their  eliminative  effects,  the 
most  prominent  are  various  diuretics,  alkalies,  and  colchicum.  It 
would  be  out  of  place  to  consider  the  relative  merits  of  these,  and 
it  suffices  to  say,  in  so  far  as  each  or  all  may  possess  the  efficacy 
claimed  for  them,  it  is  not  unreasonable  to  conjecture  that  the}''  are 


TKEATMENT    OF    ACUTE    PERICARDITIS.  347 

useful  after  pericarditis  has  been  developed.  Our  knowledge  with 
respect  to  this  point,  however,  is  not  sufficiently  precise  to  render 
it  judicious  to  trust  to  eliminative  measures  in  rheumatic  pericar- 
ditis, to  the  exclusion  or  depreciation  of  other  therapeutical  means 
of  more  direct  application  in  the  treatment  of  the  disease. 

These  remarks  will  apply,  measurably,  to  pericarditis  as  deve- 
loped in  connection  with  Bright's  disease.  The  morbid  material 
here  is  supposed  to  be  urea,  or  the  products  of  its  decomposition  in 
the  blood.  The  remedies  supposed  to  act  as  eliminatives  are  diu- 
retics, cathartics,  and  sudorifics.  As  regards  the  .employment  of 
these  remedies  with  a  view  to  elimination,  in  pericarditis,  it  is  im- 
portant to  remark  that  they  are  contra-indicated,  not  only  when 
they  come  into  opposition  to  other  measures  of  greater  importance, 
but  when,  irrespective  of  their  eliminative  operation,  they  are  likely 
to  prove  hurtful.  This  remark  applies  more  particularly  to  active 
purgative  remedies.  The  probability  of  good  being  effected  by 
means  of  elimination  is  not  sufficient  to  warrant  taking  the  risk 
of  doing  injury.  Eemedies  to  act  on  the  kidneys  and  skin  may  be 
given  more  safely.  As  a  sudorific,  Dr.  Walshe  advocates  especially 
the  hot  air  or  vapor  bath,  which  has  these  advantages  over  the 
warm  bath,  viz.,  it  may  be  taken  with  the  head  moderately  low,  and 
without  exertion  on  the  part  of  the  patient. 

Having  noticed  the  more  important  of  the  therapeutical  measures 
embraced  in  the  treatment  of  acute  pericarditis,  the  practical  points 
which  have  been  presented  may  be  recapitulated,  and  others  added, 
in  considering  briefly  the  indications  which  belong,  respectively, 
to  the  successive  periods  of  the  disease,  viz.,  prior  to,  during,  and 
after  liquid  effusion. 

Treatment  prior  to  liquid  effusion. 

The  chief  objects  of  treatment  in  this  period  are,  abatement  of 
the  intensity  of  the  inflammation ;  limitation  of  the  products  of 
inflammation  (serum  and  lymph),  and,  perhaps,  by  effecting  these 
objects,  shortening  the  duration  of  the  disease.  The  means  which 
may  be  employed  for  these  ends  are,  bloodletting,  mercurialization, 
opium,  and  eliminatives. 

Bloodletting,  as  a  rule,  is  appropriate  only  in  cases  of  idiopathic, 
and  in  certain  cases  of  rheumatic  pericarditis.  It  is  contraindi- 
cated  by  coexisting  Bright's  disease,  anaemia,  feebleness,  or  a  broken 
constitution.     It  is  rarely,  if  ever,  indicated  when  pericarditis  occurs 


348  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

in  connection  witli  tbe  eruptive  or  continued  fevers,  pyasmia,  etc 
It  should  be  employed  only  when  the  inflammation  has  a  certain 
degree  of  intensity,  or  shown  by  febrile  movement  and  a  firm  pulse. 
The  repetitions  of  bloodletting,  and  the  amount  of  blood  with- 
drawn, are  to  be  determined  by  the  symptoms  and  the  effect,  bear- 
ing in  mind  the  danger  of  weakening  too  much  the  heart  by  this 
measure.  It  is  to  be  employed  only  when  physical  exploration  of 
the  chest  affords  evidence  that  an  abundant  effusion  of  liquid  has 
not  yet  taken  place. 

Mercurialization  is  appropriate  only  in  cases  of  either  idiopathic 
or- rheumatic  pericarditis,  and  when  the  constitution  of  the  patient 
is  not  greatly  impaired  from  any  cause.  Anosmia  constitutes  a 
contra-indication.  If  this  measure  be  employed,  the  system  should 
be  brought  rapidly  under  the  effects  of  mercury,  but  it  is  never 
necessary  to  induce  severe  ptyalism ;  on  the  contrary,  this  is  to  be 
avoided,  if  possible.  Patients  with  this  disease  are  often  mercurial- 
ized with  difficulty.-  When  this  is  found  to  be  the  case,  it  is  better 
to  relinquish  the  attempt,  than  to  introduce  a  quantity  of  the 
remedy  into  the  system,  which  may,  in  the  end,  lead  to  excessive 
effects. 

Opium  is  safer  and  more  reliable  than  either  bloodletting  or 
mercurialization.  It  may  be  employed  in  the  cases  in  which  these 
measures  are  contra-indicated;  and  it  may  be  employed  in  conjunc- 
tion with  them.  It  should  be  given  in  doses  suf&cient  to  relieve 
pain  and  tranquillize  the  circulation.  The  doses  required  to  pro- 
duce a  sufficient  effect  will  sometimes  be  large,  owing  to  the  toler- 
ance of  the  remedy  in  this  disease. 

Eliminatives  are  appropriate,  with  proper  restrictions,  in  cases  in 
which  the  disease  is  dependent  on  rheumatism  or  urasmia.  These 
remedies,  however,  are  subordinate  to  those  which  have  a  more 
direct  influence  on  the  disease. 

Treatment  during  liquid  effusion. 

The  chief  objects  of  treatment  in  this  period  are,  to  prevent  the 
progressive  accumulation  of  liquid ;  to  promote  its  resorption ;  to 
invigorate  the  heart  and  obviate  danger  from  paralysis  and  com- 
pression of  the  organ.  The  means  for  these  ends  are,  mercury, 
opium,  counter-irritation,  stimulants,  nutritious  diet,  and  to  these 
may  be  added,  diuretics  and  hydragogue  cathartics. 

The  effusion  of  liquid  does  not  contra-indicate  mercurializatiou, 


TREATMENT    OF    ACUTE    PERICARDITIS.  349 

if  the  precautions  already  referred  to,  be  observed.  Limitation  of 
the  products  of  inflammation  is  still  an  object  of  treatment ;  and 
one  of  the  grounds  on  which  mercury  is  advocated,  is  its  influence 
in  promoting  resorption  of  these  products.  Still  greater  care,  how- 
ever, is  to  be  observed  in  employing  this  measure  after,  than  before 
the  disease  has  advanced  to  the  second  period. 

Indications  for  opium  may  be  present  in  the  second,  as  well  as  in 
the  first  period,  but  not  to  the  same  extent.  To  relieve  pain  and 
quiet  irritation,  are  still  objects  of  treatment,  and  this  remedy  is 
indicated  in  doses  sufficient  to  effect  these  objects. 

Vesication  upon  or  near  the  prsecordia,  which  is  not  admissible 
in  the  first  period,  is  now  useful  in  promoting  resorption,  and  also 
by  way  of  revulsion.  In  order  not  to  interfere  with  physical  exa- 
minations of  the  chest,  by  means  of  which  the  progress  of  the  dis- 
ease, from  day  to  day,  is  ascertained,  it  is  preferable  to  apply  blisters 
in  the  neighborhood  of  the  pra^cordia,  and  not  directly  over  the 
heart.  The  employment  of  a  series  of  blisters  applied  in  different 
situations,  allowing  the  blistered  surface  to  heal  as  quickly  as  pos- 
sible, is  best  suited  to  promote  absorption,  whilst  perpetuated 
blisters  are,  perhaps,  most  likely  to  act  as  revulsives. 

Diffusible  stimulants  are  indicated,  in  the  second  period,  by  weak- 
ness of  the  heart.  They  are  indicated  in  proportion  as  the  heart 
becomes  weakened  by  paralysis  and  compression.  Weakness  of  the 
heart  is  manifested  by  the  pulse  and  other  symptoms ;  but  more 
distinctly  by  physical  signs.  Feebleness  or  suppression  of  the  apex- 
beat,  diminished  intensity  of  the  heart-sounds,  more  especially  of 
the  first  sound,  and  extinction  of  the  latter,  call  imperatively  for 
m.easures  to  invigorate  the  heart.  Alcoholic  stimulants,  in  the  form 
of  either  wine  or  spirits,  are  the  most  efficient  means  for  this  end. 
They  should  be  given  as  freely  as  they  are  found  to  be  well  borne, 
the  criterion  being,  not  a  certain  quantity,  but  a  certain  effect.  The 
desired  effect  is  increased  strength,  with  diminished  frequency,  of 
the  pulse.  The  physical  signs  also  afford  a  guide  in  regulating  the 
quantity  of  stimulants.  The  reappearance  or  increased  force  of  the 
apex-beat,  and  an  approximative  return  of  the  sounds  of  the  heart 
to  their  normal  relative  intensity — in  other  words,  improvement  in 
the  first  sound  more  particularly — denote  the  beneficial  influence 
of  stimulation.  * 

In  conjunction  with  stimulants,  a  nutritious  diet  is  indicated. 
Whenever  stimulants  are  useful,  the  diet  cannot  be  too  nutritious. 
Animal  essences  or  tender  meat  itself,  constitute  the  diet  which  is 


350         INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

most  sustaining.  But  those  articles  of  food  are  of  course  to  be 
selected  wliich  are  best  adapted  to  the  digestive  powers  in  indi- 
vidual cases,  and  this  is  to  be  determined  by  experimental  trials. 

Diuretics  and  hydragogue  cathartics  may  sometimes  be  employed 
with  advantage,  with  a  view  to  promote  resorption  of  the  effused 
liquid.  But  the  employment  of  these  remedies  demands  great  cir- 
cumspection. They  are  contra-indicated  whenever  stimulants  and 
sustaining  diet  are  required.  This  caution  has  reference  more  to 
hydragogue  cathartics  than  to  diuretics,  but  measurably  to  the 
latter. 

Eliminative  remedies  may  be  continued,  "under  proper  restric- 
tions, into  the  second  period.  They  must  not  conflict  with  other 
measures  upon  which  greater  reliance  is  to  be  placed. 

Aside  from  the  indications  just  mentioned,  purgative  remedies 
are  not  advisable  in  the  treatment  of  pericarditis,  save  to  obviate 
discomfort  attending  constipation. 

It  will  not  be  amiss  to  repeat  the  caution  not  to  permit  much 
exertion  on  the  part  of  the  patient,  when  the  heart  is  compressed 
by  an  abundant  accumulation  of  liquid  effusion.  Sudden  and  fatal 
syncope  may  be  induced  by  the  effort  of  rising  from  the  bed  to  go 
to  stool,  as  in  an  instance,  referred  to  more  than  once,  which  came 
undef  my  observation. 

The  importance  of  daily  or  frequent  explorations  of  the  chest, 
in  order  to  determine  the  progressive  diminution  of  the  liquid 
effusion,  and  its  final  disappearance,  has  been  repeatedly  referred 
to,  but  it  cannot  be  too  strongly  enforced. 

Treatment  after  the  absorption  of  liquid  effusion. 

The  chief  object  of  treatment  in  this  period  is  to  promote  the  com- 
plete disappearance  of  inflammation.  The  means  for  this  end  are, 
counter-irritation,  tonic  remedies,  an  invigorating  diet  and  regimen. 

It  is  highly  probable  that  moderate,  persisting  counter-irritation 
near  the  prtecordia  tends,  by  way  of  revulsion,  to  expedite  the  final 
cessation  of  inflammation,  and  perhaps,  in  some  cases,  to  prevent  it 
from  becoming  chronic.  The  modes  of  counter-irritation  suited  to 
this  object,  which  have  been  mentioned,  are,  perpetuated  blisters, 
issues,  and  pustulation  with  croton  oil.  The  counter-irritation 
should  be  so  restricted  in  degree  as  not  to  produce  constitutional 
disturbance,  nor  prove  a  source  of  exhaustion.  Without  this  pre- 
caution, the  evils  would  be  likely  to  overbalance  the  revulsive  effect. 


TEEATMENT    OF    ACUTE    PEEICAKDITIS.  351 

In  acute  inflammations  generally,  the  local  processes  of  restora- 
tion go  on  more  rapidly,  the  liability  to  relapse  is  less,  and  the  final 
recovery  is  more  complete,  in  proportion  as  the  general  powers  of 
the  system  are  invigorated.  Hence,  one  great  advantage  in  not 
employing  unnecessarily,  during  the  progress  of  the  disease,  debili- 
tating measures  of  treatment.  The  less  the  patient  is  enfeebled,  the 
more  speedy  and  safe  the  convalescence.  Hence,  tonic  remedies,  a 
nutritious  diet,  cheerful  relaxation  of  mind,  and  gentle  exercise  in 
the  open  air,  are  important  so  soon  as  convalescence  is  established. 
These  are  the  means  by  which  the  body  regains  strength  and  vigor. 
They  are  applicable  to  pericarditis  as  well  as  to  other  inflamma- 
tions. While  undue  exertion  of  body  or  mind,  imprudent  expo- 
sure, and  excesses  of  all  kinds,  are,  of  course,  to  be  avoided,  the 
regimen  and  diet  best  calculated  to  restore  or  improve  the  general 
health  will  affect  most  favorably  the  condition  of  the  organ  recently 
inflamed. 

In  the  treatment  of  pericarditis,  associated  affections,  especially 
endocarditis,  pleurisy,  and  pneumonia,  will  often  claim  attention. 
The  measures  to  be  directed  to  these  affections  need  not  be  here 
considered.  The  treatment  of  the  pericarditis,  it  is  obvious,  must 
be  more  or  less  modified  under  these  circumstances.  As  a  rule, 
they  enforce  greater  circumspection  in  the  use  of  debilitating 
remedies,  and  call  for  an  earlier  and  more  efficient  employment  of 
sustaining  measures. 

The  danger  in  cases  of  pericarditis  is  much  enhanced  when  the 
disease  is  complicated  with  notable  disorder  of  the  nervous  system, 
giving  rise  to  active  delirium,  convulsions,  etc.,  symptoms  which, 
it  has  been  seen,  often  mask  the  cardiac  affection.  It  is  not  easy 
to  decide,  with  our  present  knowledge,  as  to  the  measures  most 
likely  to  prove  successful  in  this  class  of  cases.  In  the  case  under 
my  observation  which  ended  in  recovery,  the  treatment  consisted 
of  the  free  use  of  alcoholic  stimulants,  sustaining  diet,  and  a  blister 
upon  the  prtecordia. 


SUBACUTE    AND    CHRONIC    PERICARDITIS. 


Pericarditis  may  be  subacute  from  the  commencement.  This 
explains  the  latency  of  the  disease,  as  regards  symptoms,  in  certain 
cases.     In  these  cases,  when  the  attention  is  first  directed  to  the 


352  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

chest,  the  pericardial  sac  may  be  found  already  largely  distended. 
If  death  occur  during  the  period  of  efiusion,  the  liquid  is  found  to 
be  moderately  or  slightly  turbid,  a  small  quantity  of  lymph  adher- 
ing, in  circumscribed  patches,  to  the  pericardial  surfaces.  The 
disease  is  analogous  to  subacute  pleurisy,  as  the  latter  is  not  infre- 
quently presented  in  medical  practice.  In  other  instances,  this 
variety  of  the  disease  succeeds  the  acute  form.  In  acute  pericarditis, 
if  the  inflammation  do  not  disappear  in  the  course  of  from  two  to 
three  weeks,  the  disease  may  be  considered  as  having  become 
chronic. 

The  anatomical  conditions  in  chronic  pericarditis,  more  especially 
when  it  follows  an  acute  affection,  are  quite  different  in  different 
cases.  It  suffices  to  arrange  these  differences  into  two  classes,  viz.. 
First.  Absence  of  liquid  effusion,  and  the  pericardial  surfaces  agglu- 
tinated by  interposed  layers  of  lymph,  of  variable  thickness,  with- 
out, or  with  only  imperfectly  organized  attachment ;  Second.  More 
or  less  distension  of  the  pericardial  sac  with  turbid  serum,  puruloid, 
and  even  truly  purulent  liquid.  Upon  these  two  classes  of  anatomical 
conditions,  may  be  based  a  division  into  chronic  pericarditis  with, 
and  chronic  pericarditis  without  liquid  effusion. 

In  chronic  pericarditis  without  effusion,  adhesion  of  the  peri- 
cardial surfaces  by  organized  attachment,  is  prevented  by  the 
abundance  of  lymph.  The  latter  often  forms  a  series  of  layers 
which  may  be  successively  peeled  off  from  the  surface  of  the  heart. 
These  layers  are  dense,  resembling  membranous  structure,  but  the}' 
are  not  organized.  The  pericardial  surface  beneath  presents  the 
appearances  of  inflammation,  and  frequently  in  detaching  the  layers 
of  lymph,  small,  circumscribed  collections  of  sero-purulent  liquid 
are  discovered.  The  adherence  of  the  layers  of  lymph  to  the  vis- 
ceral and  parietal  surfaces  of  the  pericardium,  and  to  each  other, 
may  be  quite  firm,  but  it  is  only  by  mechanical  agglutination. 
The  deeper  layers  of  lymph  are  often  colored  with  hsematin. 

A  low  grade  of  inflammation  is  probably  kept  up  by  the  presence 
of  the  lymph  in  these  cases,  which  acts  like  a  foreign  substance, 
or,  successive  attacks  of  subacute  inflammation  are  frequently  re- 
newed. More  or  less  enlargement  of  the  heart  is  apt  to  follow,  and, 
in  some  instances,  perhaps,  atrophy  of  the  organ.  These  cases  are 
hopeless  as  regards  ultimate,  complete  recovery,  applying  the  term 
recovery  to  the  cessation  of  inflammation,  with  the  occurrence  of 
organized  adhesion  of  the  pericardial  surfaces,  to  a  greater  or  less 
extent. 


CHRONIC    PERICARDITIS.  oo3 

In  chronic  pericarditis  with  effusion,  the  accumulation  of  liquid 
is  often  much  greater  than  in  cases  of  the  acute  form  of  the  disease. 
The  pericardial  sac,  from  long-continued  distension,  yields  to  the 
pressure,  becomes  more  or  less  dilated,  and  the  amount  of  eQ"usion 
in  some  instances  is  enormous.  Perhaps  the  most  remarkable  case 
of  large  accumulation  on  record  was  observed  by  Prof.  Alonzo 
Clark,  and  reported  by  Dr.  Swett.^  Death  occurred  in  ten  weeks 
from  the  date  of  the  attack,  and  on  examination  iwst-mortem  "  the 
pericardium  was  found  to  occupy  the  whole  anterior  part  of  the 
chest,  pushing  the  diaphragm  downwards  so  as  to  form  a  very 
large  convexity  towards  the  cavity  of  the  abdomen.  The  liver  was 
pushed  downwards  so  that  its  upper  convex  margin  reached  the 
margin  of  the  ribs,  and  both  lungs  were  pushed  into  the  posterior 
and  lateral  portions  of  the  thorax.  Had  the  entire  contents  of  the 
pericardial  sac  been  fluid,  it  could  not  have  been  less  than  ten 
pints ;  but,  as  it  was,  there  was  at  least  a  gallon  of  clear,  yellow 
serum."  Cases  in  which  the  accumulation  amounts  to  from  two  to 
three  pints  are  not  very  uncommon.  The  sac,  when  dilated  much 
beyond  its  normal  capacity,  becomes  enlarged  disproportionately  in 
width.  Its  pyriform  shape  is  not  preserved,  as  it  is  in  acute  peri- 
carditis. In  proportion  to  its  abnormal  size,  it  occupies,  of  course, 
space  at  the  expense  of  the  pulmonary  organs,  and  interferes  with 
the  thoracic  and  diaphragmatic  movements  in  respiration. 

Chronic  pericarditis  without  liquid  effusion  is  often  unattended 
by  symptoms  which  point  to  the  seat  of  disease.  Acute  pain  is 
rarely  present.  A  sense  of  uneasiness,  constriction,  or  indefinite 
distress,  may  be  referred  to  the  pr^ecordia;  palpitation  may  be 
complained  of  with  dyspnoea,  on  exertion ;  but  there  may  be  entire 
absence  of  all  subjective  symptoms  referable  to  the  heart.  Feeble- 
ness or  disordered  action  sufficient  to  give  rise  to  symptomatic 
phenomena  denoting  plainly  cardiac  disease  may  not  occur  until 
structural  lesions  have  been  induced. 

The  presence  of  an  abundant  liquid  effusion  will  be  likely  to 
give  rise  to  symptoms  directing  attention  to  the  chest,  but  not 
distinctive  of  the  disease.  The  symptoms  are  essentially  those 
incident  to  the  period  of  effusion  in  acute  pericarditis,  viz.,  palpita- 
tion, feebleness  and  irregularity  of  the  pulse,  prsecordial  distress, 
dyspnoea,  and  tendency  to  syncope,  especially  on  exertion,  lividity, 
oedema,  etc.     These  symptoms  may  be  less  marked  than  in  acute 

'  Lectures  on  Diseases  of  the  Chest,  1852,  p.  394. 

23 


OO-I  IXFLAMMATORY    AFFECTIONS    OF    TUE    IIEAET. 

pericarditis,  although  a  much  larger  quantity  of  liquid  may  be 
contained  in  the  pericardial  sac,  the  accumulation  taking  place 
more  slowly,  or  greater  tolerance  being  acquired.  But  even  when 
considerable  effusion  exists,  the  disease  may  be  latent  as  regards 
subjective  and  objective  symptoms  (exclusive  of  physical  signs) 
distinctly  referable  to  the  heart. 

The  physical  signs,  when  liquid  effusion  is  not  present,  are  not 
distinctive  of  existing  chronic  inflammation.  Certain  signs  may  be 
present  denoting  union  of  the  pericardial  surfaces,  but  not  indica- 
ting the  mode  of  this  union.  These  signs  will  be  noticed  under  the 
head  of  pericardial  adhesions.  Creaking  friction-sound  is  occasion- 
ally discovered.  The  disease,  in  fact,  under  these  circumstances, 
frequently  does  not  offer  strongly-marked  diagnostic  phenomena ; 
and,  without  an  acquaintance  with  the  previous  history,  it  is  by  no 
means  easy  to  arrive  at  a  positive  diagnosis.  Knowledge  of  the 
fact  that  acute  pericarditis  has  recently  existed,  taken  in  connection 
with  the  symptoms  and  signs,  will  be  a  guide  to  the  diagnostician. 
These  cases,  when  not  preceded  by  acute  pericarditis,  or  when  they 
come  under  observation  after  the  inflammation  has  ceased  to  be 
acute,  are  generally  overlooked.  If,  as  is  often  the  case,  valvular 
lesions  and  enlargement  of  the  heart  coexist,  the  symptoms  and 
signs  may  be  referred  exclusively  to  these,  pericarditis  not  being 
suspected. 

An  abundant  liquid  effusion  gives  rise  to  physical  signs  which 
have  been  already  considered  in  connection  with  acute  pericarditis. 
The  signs  do  not  differ  from  those  in  the  latter  affection,  except  so 
far  as  they  are  modified  by  the  existence,  often,  of  a  much  larger 
accumulation  of  liquid  than  occurs  in  the  acute  form  of  the  disease. 
The  space  occupied  by  a  largely  dilated  pericardial  sac  is,  of  course, 
proportionately  greater  than  when  the  sac  is  merely  distended  ; 
and  the  form  of  the  sac  being  altered  by  its  greater  relative  width, 
the  area  of  dulness  on  percussion  corresponding  to  the  space  which 
it  occupies,  does  not  present  the  pyriform  shape  characteristic  of 
the  outline  of  dulness  in  acute  pericarditits.  The  dulness  on  per- 
cussion, in  proportion  as  the  amount  of  liquid  is  greater,  is  more 
marked  in  degree,  approaching  more  nearly  to  absolute  flatness. 
The  auscultatory  signs  show  removal  of  the  anterior  margins  of  the 
lung  on  each  side  to  a  greater  distance  from  the  median  line,  the  ex- 
tent of  the  separation  being  in  proportion  to  the  dilatation  of  the  sac. 
A  friction-sound,  in  some  instances,  is  discovered,  notwithstanding  a 
very  large  accumulation  of  liquid.     The  apex-beat  is  suppressed ; 


CHRONIC    PERICARDITIS.  855 

but  a  diffused  shock  may  be  felt  over  the  pnecordia.  The  latter 
was  observed  in  the  case  of  enormous  accumulation  reported  by 
Dr.  Swett.  It  was  gbserved  in  that  case,  that  the  limits  of  dulness 
OD  percussion  moved  nearly  an  inch  to  the  right  or  left,  according 
as  the  position  of  the  patient  was  on  the  right  or  left  side,  the 
extent  of  the  dulness  undergoing  no  change.  This  variation  in 
situation  of  the  area  of  dulness,  with  change  of  position,  in  cases  of 
pericardial  effusion,  has  been  observed  in  other  cases.  Enlarge- 
ment or  bulging  of  the  precordial  region  is  more  apt  to  be  marked 
in  chronic  than  acute  pericarditis,  in  consequence  of  the  larger 
collection  of  liquid.  The  depression  of  the  diaphragm  may  be 
sufficient  to  cause  marked  swelling  at  the  epigastrium,  and  even 
an  unusual  prominence  of  the  abdomen.  Undulation  in  the  inter- 
costal spaces  is  oftener  observed  in  chronic  than  acute  pericarditis. 
In  the  case  reported  by  Dr.  Swett,  it  was  perceived  in  the  epigas- 
trium. The  left  lung  is  sometimes  pressed  upward,  to  a  consider- 
able height,  above  the  clavicle.  Dr.  Stokes  cites  a  case  which  came 
under  his  observation,  in  which  a  tumor  was  produced  above  the 
clavicle  sufficiently  large  to  produce  great  deformity  of  the  neck. 
This  tumor  was  present  for  several  days ;  it  was  increased  by 
coughing,  and  gave  the  pulmonary  sound  on  percussion,  with  vesi- 
cular murmur  and.  wheezing  rale  on  auscultation.  A  similar 
instance  was  observed  by  Dr.  Graves.  The  enlargement  of  the 
chest  and  depression  of  the  diaphragm,  in  cases  of  very  large  effu- 
sion, will  occasion  an  obvious  restraint  of  the  costal  and  abdominal 
movements  of  respiration. 

The  differential  diagnosis  of  pericardial  effusion,  based  on  the 
physical  signs,  involves  the  same  points  in  chronic,  as  in  acute 
pericarditis,  and  these  need  not  be  repeated. 

The  objects  of  treatment  in  chronic  pericarditis  are,  the  removal, 
by  absorption,  of  the  morbid  products,  serum  and  lymph,  and  the 
final  disappearance  of  the  inflammation.  Therapeutical  measures 
having  reference  to  these  objects,  are,  mercurialization,  except  when 
contra-indicated  by  circumstances  which  have  been  mentioned; 
vesication  and  other  modes  of  counter-irritation,  and  the  use  of 
certain  remedies  which  are  supposed  to  act  as  sorbefacients,  of 
which  the  most  prominent  is  iodine.  Iodine  has  been  supposed 
to  act  efficiently,  in  some  instances,  when  applied  externally.  This 
method  is  recommended  by  Dr.  Stokes. 

But  the  treatment  must  be  governed,  in  a  great  measure,  by  cir- 
cumstances which   have  reference  indirectly  to  the  objects  just 


856  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

Stated,  viz.jthe  morbid  anatomical  conditions  as  respects  the  presence 
or  absence  of  liquid  effusion ;  the  vital  condition  of  the  heart,  or, 
in  other  words,  the  weakness  of  the  organ ;  coexisting  affections, 
and  the  constitution  of  the  patient.  The  solid  products  of  inflam- 
mation, consisting  of  thick  layers  of  condensed  lymph,  cannot  be 
removed  by  sorbefacient  remedies.  More  is  to  be  expected  from 
efforts  to  promote  the  resorption  of  liquid  effusion ;  but  if  the  peri- 
cardial sac  be  much  dilated  and  the  liquid  puruloid,  the  prospect  of 
success  is  small.  In  proportion  to  the  weakness  of  tbe  heart,  stimu- 
lants are  called  for.  Coexisting  affections  will  claim  appropriate 
attention,  and  the  general  condition  of  the  system  will  be  likely  to 
contra-indicate  therapeutical  measures  which  tend  to  impair  the 
vital  forces,  and,  on  the  other  hand,  to  indicate  a  sustaining  course 
of  treatment. 

In  cases  of  large  dilatation  of  the  pericardial  sac  with  liquid, 
which  does  not  diminish  under  appropriate  remedies,  and  gives 
rise  to  distress  and  danger  from  compression  of  the  heart  and  out- 
ward pressure  on  the  adjacent  parts,  the  propriety  of  puncturing 
the  pericardium  is  to  be  considered.  This  operation  has  been 
repeatedly  performed,  with  immediate  relief  of  distressing  symp- 
toms, apparent  prolongation  of  life,  and  in  some  instances  perhaps 
it  has  been  followed  by  recovery.^  Assuming  the  diagnosis  to  be 
clear,  and  that  other  measures  have  proved  ineffectual,  paracentesis 
is  certainly  warranted,  even  as  a  means  of  temporary  relief.  Com- 
parative comfort  and  postponement  of  a  fatal  result  may  reasonably 
be  expected  from  the  operation.  That  recovery  is  not  to  be  looked 
for  in  the  great  majority  of  cases  arises  from  the  almost  hopeless- 
ness of  chronic  pericarditis,  irrespective  of  the  danger  incident  to 
the  quantity  of  liquid  accumulation.  Further  observations  may 
show  that  the  operation  is  to  be  resorted  to  in  cases  in  which  the 
sac  is  largely  distended  or  dilated,  when  the  distress  is  not  extreme 
and  the  danger  not  imminent.  It  may  perhaps  be  shown  by  expe- 
rience to  be  applicable  to  the  treatment  of  acute  as  well  as  chronic 
pericarditis.  The  success  with  which  paracentesis  has  of  late  been 
employed  in  cases  of  pleurisy,  by  Dr.  Bowditch  and  others,  war- 

'  This  statement  is  made  with  the  qualifying  -word  'perhaps;'  for  although  it  is 
stated  that  the  operation  has  in  some  hands  been  successful,  I  am  unable  to  refer 
to  reports  of  cases  which  afford  evidence  that  recovery  was  complete.  For  a  risumt 
of  cases  which  have  been  reported,  numbering  thirteen,  the  reader  is  referred  to 
Bellingham's  work,  pt.  ii.  p.  330. 


PNEUMO-PERICARDITIS.  357 

rants  a  conjecture  that  the  same  measure  may  be  extended  equally 
to  pericarditis  with  effusion. 

In  performing  paracentesis  of  the  pericardium,  the  method  prac- 
tised by  Dr.  Bowditch  in  cases  of  pleurisy  is  to  be  preferred.  This 
method  consists  in  the  introduction  of  a  small  exploring  trocar, 
to  the  canula  of  which  is  attached  a  suction-pump.  The  wound 
made  by  this  instrument  is  trivial,  the  liquid  may  be  withdrawn 
slowly,  the  quantity  regulated  by  the  immediate  effects,  and  the 
operation  repeated  as  often  as  may  be  deemed  advisable.  The 
trocar  is  to  be  introduced  in  the  fourth  or  fifth  intercostal  space 
between  the  nipple  and  the  sternum,  the  patient  lying  upon  the 
back ;  the  physical  signs  showing  the  pericardium  to  be  in  contact 
with  the  thoracic  walls  at  the  point  of  puncture,  and  the  heart 
removed  from  the  walls  at  that  situation.  M.  Aran,  of  Paris,  has 
reported  a  case  in  which  a  solution  of  iodine  was  injected,  after  the 
removal  of  the  liquid,  with  apparent  benefit. 


PNEUMO-PERICARDIUM   AND   PNEUMO-PERICARDITIS. 


Air  or  gas  gains  access  within  the  pericardium  by  means  of 
fistulous  communications  with  the  stomach,  oesophagus,  or  the  pul- 
monary organs;  or  through  wounds  of  the  chest  perforating  the 
pericardial  sac;  and  in  rare  instances  it  is  generated  by  the  decom- 
position of  liquid  products  within  the  sac.  Inflammation,  with  more 
or  less  liquid  effusion,  is  almost  invariably  present.  The  affection 
is  then  properly  designated  pneumo-pericarditis.  It  is  analogous  to 
that  variety  of  pleuritis  which  is  commonly  known  by  the  incorrect 
title — pneumo-hydrothorax.  But  inflammation  is  not  necessarily 
present.  In  a  case  related  to  me  by  Dr.  Knapp,  of  Louisville,  to 
which  reference  has  before  been  made,  a  patient  was  stabbed  with 
a  knife,  which  penetrated  the  pleural  cavity  and  perforated  slightly 
the  pericardium.  A  splashing  sound  with  the  heart's  action  was 
immediately  heard,  which  continued  for  a  few  days  and  disappeared. 
The  symptoms  and  signs,  subsequently,  did  not  denote  pericarditis, 
but  the  patient  had  pleurisy,  which  was  followed  by  considerable 
contraction  of  the  left  side.  The  splashing  sound,  in  this  case,  was 
fairly  attributable  to  the  presence  of  air  and  probably  a  little  blood 


358  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

within  the  pericardium.  The  recovery  was  complete,  and  the  pa- 
tient was  examined  by  me  some  two  or  three  years  after  the  injury. 
In  such  a  case,  the  affection,  assuming  that  inflammation  was  not 
present,  is  properly  called  pneumo-pericardium. 

Dr.  Stokes  relates  a  case  in  which  the  coexistence  of  liquid  and 
gas  was  predicated  on  the  peculiar  auscultatory  phenomena.     The 
account  is  best  given  in  his  own  words.    "The  patient  was  a  young 
man  of  lymphatic  temperament,  who  had  labored  under  an  attack 
of  acute  pericarditis  for  a  few  days  before  I  saw  him.     On  my  first 
examination  he  presented  the  usual  signs  of  dry  pericarditis,  with 
a  considerable  effusion  of  lymph  of  the  ordinary  consistence.    The 
rubbing  sounds,  though  loud  and  distinct,  had  nothing  unusual  in 
their  character,  and  the  patient  suffered  but  little  distress.     After 
two  or  three  days  I  saw  him  again,  and  found  that  his  state  had 
become  very  much  altered.    His  appearance  was  haggard  and  worn, 
and  he  complained  of  extreme  exhaustion,  which  he  attributed  to 
a  total  deprivation  of  sleep.    This  was  induced  by  the  extraordinary 
loudness  and  singular  character  of  the  sounds  proceeding,  from  the 
cardiac  region ;  for  though  up  to  this  period  the  rubbing  sounds 
were  distinctly  perceptible  by  means  of  the  stethoscope,  the  patient 
was  quite  unconscious  of  their  existence.    They  had  suddenly,  how- 
ever, become  so  loud  and  singular,  that  the  patient  and  his  wife, 
who  occupied  the  same  apartment,  were  unable  to  obtain  a  mo- 
ment's repose.     On  examination,  a  series  of  sounds  was  observable 
which  I  had  never  before  met  with.     It  is  difficult  or  impossible  to 
convey  in  words  any  idea  of  the  extraordinary  phenomena  then 
presented.    They  were  not  the  rasping  sounds  of  indurated  lymph, 
nor  the  leather  creak  of  Collin,  nor  those  proceeding  from  pericar- 
ditic  with  valvular  murmur,  but  a  mixture  of  the  various  attrition 
murmurs  with  a  large  crepitating  and  a  gurgling  sound,  while  to 
all  these  phenomena  was  added  a  distinct  metallic  character.     In 
the  whole  of  my  experience  I  never  met  with  so  extraordinary  a 
combination  of  sounds.     The  stomach  was  not  distended  with  air, 
and  the  lung  and  pleura  were  unaffected,  but  the  region  of  the 
heart  gave  a  tympanitic  hruit  de  pot  fele  on  percussion;  and  I  could 
form  no  conclusion  but  that  the  pericardium  contained  air  in  addi- 
tion to  an  eff"usion  of  serum  and  coagulable  lymph.     In  the  course 
of  about  three  days  the  signs  of  air  disappeared,  leaving  the  phe- 
nomena as  they  were  at  the  first  period  of  the  case.     The  conva- 
lescence of  this  patient  was  slow,  and  the  rubbing  sounds  continued 


PNEUMO-PERICARDITIS.  859 

for  an  unusual  length  of  time.  Ilis  recovery  was  ultimately  per- 
fect."^ 

Dr.  Stokes,  in  connection  with  this  case,  cites  two  additional 
cases,  one  reported  by  Dr.  Graves,  and  the  other  communicated  by 
Dr.  B.  McDowel.  In  Dr.  Graves'  case,  pericarditis  was  induced  by 
the  opening  of  a  hepatic  abscess  into  the  pericardial  sac.  The  case 
proved  fatal,  and  after  death  it  was  ascertained  that  the  abscess  also 
communicated,  through  a  fistulous  opening,  with  the  stomach.  The 
gas  contained  within  the  pericardium  was  derived  from  the  stomach 
passing  through  the  hepatic  abscess.  The  patient  presented  over 
the  prgecordia  friction-sounds,  with  an  occasional  metallic  click, 
giving  the  idea  of  a  fluid  dropping  in  the  pericardium.  Afterwards 
the  sounds  assumed  the  character  of  an  emphysematous  crackling. 
In  Dr.  McDowel's  case,  a  fistula  was  found,  after  death,  to  have  be- 
come established  between  the  pericardial  sac  and  a  small  anfractuous 
cavity  in  the  right  lung.  A  current  of  air  through  the  trachea  was 
observed  to  rise  through  the  fluid  contained  in  the  pericardial  sac, 
and  the  latter,  when  opened,  contained  air.  Over  the  left  side  of 
the  chest,  in  this  case,  auscultation  discovered  metallic  tinkling, 
and  splashing  of  fluid  caused  by  the  action  of  the  heart. 

In  a  case  reported  by  Dr.  Walshe,  in  which  a  communication 
existed  between  the  oesophagus  and  pericardium,  produced  by  the 
effort  to  swallow  a  knife,  tympanitic  resonance  on  percussion  over 
the  prsecordia  was  marked,  but  neither  a  splashing  noise  nor  metallic 
tinkling  were  observed.  A  distinctive  phenomenon  in  this  case 
"consisted  in  the  change  of  position  of  tympanitic  and  dull  percus- 
sion-sound, within  the  area  of  the  cardiac  region,  according  as  the 
posture  of  the  patient  was  changed  from  one  to  the  other  side." 

These  cases  are  of  much  interest  as  showing  the  physical  signs 
distinctive  of  the  presence  of  air  or  gas  and  liquid  within  the  peri- 
cardium. The  auscultatory  signs  which  may  be  expected  to  be 
present  are,  metallic  ti'nkling  sounds,  and  a  splashing  or  gurgling 
noise,  produced  by  the  action  of  the  heart.  Their  connection  with 
the  heart  is  to  be  determined,  if  there  be  room  for  doubt,  by  re- 
questing a  momentary  holding  of  the  breath.  They  are  not,  how- 
ever, invariably  present,  as  shown  by  the  case  reported  by  Dr. 
Walshe.  Tympanitic  resonance  on  percussion  over  more  or  less, 
of  the  prfficordia  is  marked.  In  the  case  observed  by  Dr.  Stokes,  a 
distinct  hruil  de  iM  ftU  was  observed;  and  in  Dr.  Walshe's  case 

'  On  Diseases  of  the  Heart  and  Aorta,  Am.  ed.,  p.  38. 


360  INFLAMMATORY    AFFECTI0X3    OF    THE    HEART. 

variation  in  the  relative  position  of  tympanitic  resonance  and  dul- 
ness,  with  change  of  posture.  The  production  of  a  peculiar  noise, 
so  loud  as  not  only  to  be  heard  by  the  patient  and  others,  but  to 
prevent  persons  from  sleeping  in  the  same  apartment,  is  a  remark- 
able and  highly  distinctive  feature  in  Dr.  Stokes'  case. 

The  physical  signs,  in  connection  with  the  history  and  symptoms, 
seem  to  be  amply  sufficient  for  the  diagnosis.  There  is  a  possi- 
bility that  considerable  distension  of  the  stomach  with  gas  and 
liquid,  may  give  rise  to  acoustic  phenomena  resembling  those  pro- 
duced in  some  cases  of  pneumo-pericardium.  But  the  evidences  of 
pericarditis  with  effusion,  under  these  circumstances,  will  be  want- 
ing. Cardiac  gastric  sounds,  probably,  require  for  their  production 
that  the  pericardial  sac  shall  be  free  from  liquid.  Again,  metallic 
tinkling,  and,  possibly,  splashing  sounds  may  be  produced  by  the 
action  of  the  heart  in  some  cases  of  pneumo-hydrothorax ;  but  it 
is  sufficiently  easy  to  exclude  the  latter  affection  by  the  absence  of 
its  diagnostic  signs. 

The  treatment  of  this  variety  of  pericarditis  does  not  claim  dis- 
tinct consideration. 


PERICARDIAL    ADHESION'S, 


Inflammation  of  the  pericardium,  ending  in  recovery,  involves, 
as  has  been  seen,  the  formation  of  new  tissue  which  often  serves  as 
a  medium  of  permanent  union  of  the  opposed  pericardial  surfaces. 
Pericarditis,  when  general,  i.  e.,  when  the  inflammation  extends 
over  the  whole,  or  the  greater  part  of  the  membrane,  is  followed  by 
this  result,  as  inflammation  of  the  pleura  is  followed  by  pleuritic 
adhesions.  The  pericardial  adhesions  now  referred  to,  differ  from 
those  which  have  been  considered  as  incident  to  a  variety  of  chronic 
pericarditis.  The  latter  are  due  to  a  stratum  of  lymph  interposed 
between  the  surfaces  of  the  pericardium,  to  which  each  pericardial 
surface  becomes  agglutinated.  The  lymph  is  unorganized,  and  is, 
in  fact,  equivalent  to  a  foreign  substance,  at  once  separating  and 
binding  together,  mechanically,  the  parietal  and  visceral  portions 
of  the  pericardium.  Under  these  circumstances,  the  pericardium  is 
rarely,  if  ever,  in  a  healthy  condition.  In  adhesions  by  means  of 
new  tissue,  the  mode  of  union  is  quite  different.     It  is  by  an  or- 


PERICARDIAL    ADHESIONS.  861 

gaaized  attachment.  The  new  structure,  when  formed,  becomes 
thereafter  an  integral  portion  of  the  organism.  These  adhesions 
are  not  incompatible  with  a  healthy  state  of  the  pericardial  mem- 
brane ;  they  do  not  necessarily  constitute  a  disease,  although  they 
are  the  effects  of  disease.  They  become  more  and  more  firm  with 
age.  Some  idea  may  be  formed  of  the  length  of  time  since  their 
formation,  by  the  force  required  for  their  separation.  It  is  cus- 
tomary to  speak  of  them  as  more  or  less  ancient.  It  is  doubtful 
whether  recovery  from  general  pericarditis  ever  takes  place  without 
leaving  more  or  less  of  these  effects.  The  adhesion  may  be  general 
or  partial ;  in  other  words,  the  surfaces  may  be  united  over  the 
whole  heart,  or  only  over  a  portion  of  the  organ.  General  adhe- 
sion appears  to  be  of  much  more  frequent  occurrence  than  partial. 
Of  70  cases  analyzed  by  Louis,  the  adhesions  were  general  in  60, 
and  partial  in  10 ;  and  of  86  cases  analyzed  by  Dr.  Chambers,  51 
were  universal,  4  nearly  so,  and  29  partial.^  When  the  adhesion  is 
general  and  close,  the  pericardium  seems  to  be  wanting,  and  it  is 
conjectured  that  some  of  the  cases  reported  by  the  early  anatomists 
of  absence  of  the  pericardium,  may  have  been  cases  of  this  descrip- 
tion. 

Pericardial  adhesions  are  found,  on  examination  after  death, 
associated,  in  a  certain  proportion  of  cases,  with  valvular  and  other 
cardiac  lesions.  They  are  also  found,  not  infrequently,  when  there 
had  been  no  suspicion  of  cardiac  disease.  They  denote,  of  course, 
that  pericarditis  has  existed  at  some  period  during  life,  and  this 
period  may  have  been  more  or  less  remote  from  the  time  of  death. 
They  constitute,  in  a  certain  proportion  of  cases,  the  only  abnormal 
condition  which  the  heart  presents.  The  practical  questions  con- 
nected with  the  subject  are:  What  effects  do  they  produce  upon 
the  heart  and  circulation,  and  how  is  their  existence  to  be  ascer- 
tained during  life  ?  These  questions,  it  is  obvious,  are  of  consider- 
able importance  practically.  They  suggest  the  most  convenient 
arrangement  for  the  consideration  of  the  subject. 

What  effects  are  produced  by  pericardial  adhesions  upon  the  heart  and 

circulation'? 

Pathologists,  for  the  most  part,  up  to  the  present  time,  have 
regarded  adhesions  of  the  pericardium  as  constituting  a  very  serious 

'  Decennium  Pathologicum,  Brit,  and  For.  Med.-Chir.  Rev.,  vol.  sii.  1853. 
Also  Bellinghain,  op.  cit. 


362  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

abnormal  condition.  Laennec  held  a  contrary  opinion,  considering 
them  as  often  harmless.  Among  recent  writers  on  diseases  of  the 
heart,  Bouillaud  concurs  in  the  opinion  of  Laennec;  but  the  doc- 
trine inculcated  bj  Hope  is,  that  they  inevitably  lead  to  enlarge- 
ment of  the  heart,  and,  sooner  or  later,  to  a  fatal  result.  Investiga- 
tions since  the  publication  of  the  last  edition  of  the  treatise  by  Hope 
show,  conclusively,  that  this  distinguished  author  was  led  to  exag- 
gerate the  evils  and  dangers  attendant  on  the  remote  consequences 
of  pericarditis. 

Pericardial  adhesions,  general,  and  evidently  of  long  standing, 
are  found,  not  infrequently,  when,  in  all  other  respects,  the  heart 
presents  a  normal,  healthy  appearance.  Cases  exemplifying  the 
correctness  of  this  statement  have  been  reported  by  Bouillaud, 
Stokes,  King,  Barlow,  W.  T.  Gairdner,  and  others.'  The  following 
instance,  which  I  find  among  my  recorded  cases,  will  serve  as  an 
illustration  :  A  male  patient,  aged  35,  was  admitted  into  the  hospital, 
in  a  state  of  unconsciousness,  and  died  fifteen  hours  after  admission. 
The  previous  history  was  not  ascertained.  On  examination  after 
death,  morbid  appearances  were  found  denoting  meningitis.  The 
heart  presented  universal,  old  adhesions.  Considerable  force  was 
required  in  separating  the  pericardial  surfaces.  The  organ  was 
apparently  not  enlarged.  It  weighed  10|  ounces.  The  walls  and 
cavities  were  normal,  and  the  muscular  substance  was  not  altered 
in  color  or  consistence.  In  this  instance,  that  the  adhesions  were 
of  ancient  date  is  inferred  from  their  firmness.  Dr.  Stokes  refers 
to  a  case  which  came  under  his  observation,  in  which,  death  occur- 
ring seven  years  after  an  attack  of  pericarditis,  the  patient,  for 
several  years,  exhibiting  no  symptoms  of  heart  disease,  the  peri- 
cardial sac  was  found  to  be  obliterated,  and  the  heart  otherwise  in 
a  perfectly  natural  condition.  The  occurrence,  in  even  a  small 
number  of  cases,  of  adhesions,  which,  after  several  years  of  exemp- 

'  For  the  convenience  of  those  who  may  wish  to  consult  the  authors  named,  the 
references  are  subjoined  as  follows  :  Stokes  on  "Diseases  of  the  Heart  and  Aorta." 
W.  King  on  "the  Harmlessness  of  Adherent  Pericardium,"  London  Lancet,  Nov., 
1845.  Article  by  Dr.  Barlow  in  "  Gulstonian  Lectures."  Dr.  W.  T.  Gairdner  on 
"  The  Favorable  Terminations  of  Pericarditis,  and  especially  in  Adhesion  of  the 
Pericardium,  with  cases  illustrating  its  Secondary  Effects  on  the  'Reaxi,'"  Edinburgh 
Monthfi/  Journal  of  Medical  Science,  1851.  Bouillaud,  in  Le<;ons  Cliniques  sur  les 
Maladies  du  Cceur,  etc.,  Paris,  1853.  The  author  last  named  states  that  he  has 
met  with  more  than  fifty  examples  of  pericardial  adhesions  in  persons  who  had 
enjoyed  good  health  for  a  long  period,  and  who  died  with  various  affections  foreign 
to  the  heart. 


PERICAEDIAL    ADHESIONS.  363 

tion  from  all  cardiac  trouble,  are  found  not  to  be  accompanied  by 
any  other  abnormal  condition  of  the  heart,  suffices  to  show  that 
they  do  not  necessarily  give  rise,  as  stated  by  Hope,  to  serious 
effects  upon  the  heart  and  circulation. 

The  foregoing  conclusion,  however,  may  be  correct,  and  yet  peri- 
cardial adhesions  exert  more  or  less  agency  in  the  development  of 
cardiac  disease  in  a  certain  number  of  cases.  It  is,  therefore,  an 
important  object  to  determine  the  proportion  of  cases  in  which  these 
adhesions  are  found  to  exist  independently  of  other  abnormal  con- 
ditions of  the  heart.  With  reference  to  this  point.  Dr.  Gairdner 
has  analyzed  15  cases  in  which  adhesions  were  found  after  death, 
the  patients  dying  from  various  diseases.  Of  these  cases,  in  10  the 
heart  was  not  enlarged,  nor  otherwise  diseased.  Of  the  remaining 
5  cases,  the  heart  was  enlarged  in  all ;  but  in  2  of  the  latter  cases, 
valvular  lesions  coexisted ;  and  in  2  the  adhesions  were  not  general, 
but  partial.  These  15  cases  were  collected  by  Dr.  Gairdner  from 
the  records  of  500  miscellaneous  post-mortem  examinations  per- 
formed in  the  Edinburgh  Infirmary,  the  cases  of  adherent  pericar- 
dium only  being  selected  in  which  the  adhesions  were  so  consider- 
able and  so  situated  as  to  restrain  the  movements  of  the  heart.  An 
analysis  of  90  cases  of  adherent  pericardium,  collected  from  mu- 
seums and  catalogues  by  Mr.  Henry  Kennedy,  of  Dublin,  yields 
results  somewhat  different  from  those  obtained  by  Dr.  Gairdner. 
Of  these  90  cases,  the  heart  remained  healthy  till  death,  in  34,  and 
was  enlarged  in  51.'  From  this  collection,  all  cases  of  valvular 
lesions  were  excluded.  Of  four  cases  of  general  adhesions  discon- 
nected from  valvular  disease,  of  which  I  have  notes  (and  also  the 
hearts,  in  my  cabinet),  in  one  only  was  the  heart  normal  in  other 
respects. '  In  three  cases  there  existed  a  moderate  degree  of  enlarge- 
ment. 

In  view  of  the  discrepancy  of  the  results  of  different  analyses, 
the  precise  ratio  of  instances  in  which  pericardial  adhesions  are 
found  not  to  be  accompanied  by  other  abnormal  conditions,  which 
may  be  considered  as  consecutive,  is  not,  as  yet,  determinable,  but 
we  are  warranted  in  concluding  that  the  proportion  is  at  least  one- 
third,  excluding  cases  in  which  they  are  associated  with  valvular 
lesions. 

It  is  evident  that,  in  order  to  determine  more  fully  the  effects 
of  adhesions  on  the  heart,  it  is  desirable  to  know,  in  the  cases  in 

'  Edinburgh  Med.  .Journal,  1858. 


364         INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

which  they  are  found  not  to  be  associated  with  any  other  abnormal 
condition,  how  long  they  have  existed  prior  to  death.  Often  this 
cannot  be  definitively  ascertained.  A  collection  of  cases  in  which 
the  length  of  time  that  had  elajDsed  after  the  occurrence  of  peri- 
carditis, is  known,  and  the  heart  examined  after  death,  would  be 
highly  valuable  with  reference  to  the  question  under  consideration. 
Adhesions  existing  in  connection  with  valvular  lesions,  are  pro- 
perly excluded  from  the  cases  analyzed  with  a  view  to  determine 
the  effects  of  the  former  upon  the  heart.  Valvular  lesions,  as  is 
well  known,  in  the  great  majority  of  cases,  lead  to  cardiac  enlarge- 
ment, so  that  when  these  lesions  coexist  with  adhesions,  and  the 
heart  is  found  to  be  enlarged,  it  is  fair  to  attribute  the  enlargement 
to  the  affection  of  the  valves.  And  when  valvular  lesions  and  ad- 
hesions are  combined,  it  may  be  concluded  that  the  inflammatory 
affections  giving  rise  to  both,  occurred  at  the  same  time,  inasmuch 
as  clinical  observation  shows  pericarditis  in  the  majority  of  cases  to 
be  conjoined  with  endocarditis.  It  is  also  to  be  considered  that 
the  association  of  adhesions  with  enlargement  of  the  heart  (valvular 
lesions  not  being  present)  does  not  prove  that  the  latter  is  an  effect 
of  the  former.  Other  causes  may  have  given  rise  to  the  enlarge- 
ment, and  the  association  may  be  merely  a  coincidence  in  some 
cases.  Again,  the  enlargement  may  have  proceeded  not  from  the 
adhesions,  but  as  a  remote  efiect  of  the  pericardial  inflammation 
on  the  substance  of  the  heart.  The  adhesions  and  the  enlargement, 
in  these  cases,  are  coinciding  effects  of  a  common  cause,  viz., 
inflammation  of  the  pericardium  without  any  causative  dependence 
on  each  other.  Still  farther,  it  is  to  be  borne  in  mind  that  a 
moderate  enlargement  of  the  heart  is  not  necessarily  a  serious 
affection.  And,  in  point  of  fact,  pericardial  adhesions  associated 
with  a  certain  amount  of  enlargement,  without  the  coexistence  of 
valvular  lesions,  are  often,  if  not  generally,  found  after  death  in 
cases  in  which  the  symptoms  had  not  denoted  any  cardiac  affection, 
and  death  was  owing  to  diseases  having  no  apparent  reference  to 
the  condition  of  the  heart.  In  view  of  the  several  considerations 
just  presented,  it  seems  to  be  a  logical  conclusion  that  pericardial 
adhesions  do  not  involve  serious  consequences  to  the  extent  which 
might  be  inferred  from  the  statistics  of  Dr.  Kennedy,  showing  that 
adhesions  and  enlargement  are  found  after  death  to  be  associated 
in  two-thirds  of  the  cases  examined,  exclusive  of  the  cases  of 
valvular  lesions.     To  these  considerations  it  may  be  added  that 


PERICAEDIAL    ADHESIONS.  365 

adhesions,  enlargement,  and  valvular  lesions  combined,  are  some- 
times borne  for  a  long  period.  This  fact  is  illustrated  by  the 
following  case :  A  male  patient,  aged  68,  was  admitted  into  the 
hospital  with  advanced  cardiac  disease,  and  died  the  day  after  his 
admission.  It  was  ascertained  that  38  years  had  elapsed  since  an 
attack  of  acute  rheumatism.  The  pericardium  was  found,  ou 
examination  after  death,  to  be  universally  and  closely  adherent  by 
firm  and  evidently  very  old  adhesions.  The  heart  weighed  46 
ounces.  The  enlargement  was  due  mainly  to  hypertrophy  and 
dilatation  of  the  left  ventricle  and  auricle,  but  the  whole  organ  was 
increased  in  size.  The  curtains  of  the  mitral  valve  were  thickened, 
contracted,  and  the  valve  evidently  insufficient.  The  aortic  valve 
was  sound. 

The  doctrine  inculcated  by  Hope  is,  that  pericardial  adhesions 
invariably  lead  to  enlargement  of  the  heart.  It  has  been  seen  that 
clinical  facts  abundantly  disprove  this  doctrine.  On  the  other 
hand,  it  has  been  recently  maintained  that  the  effect  of  adhesions  is 
precisely  the  reverse  of  this;  that  they  tend  to  produce  atrophy  of 
the  organ.  This  view  was  first  taken  by  Dr.  Chevers.'  It  is 
adopted  by  Dr.  Barlow  and  AV.  King  in  the  papers  already  referred 
to.  Professor  Smith,  of  Dublin,  thinks  that  he  has  found  atrophy 
and  hypertrophy  to  coexist  with  adhesions  in  about  an  equal  pro- 
portion of  cases.  Dr.  Stokes  advocates  this  view  on  the  ground  of 
analogy  with  the  apparent  effects  of  pleuritic  adhesions  on  the 
lungs,  and  of  mechanical  restraint  on  the  voluntary  muscles.  Dr. 
Hope  accounted  for  the  production  of  hypertrophy  on  the  principle 
that  the  heart,  being  mechanically  restrained,  was  thereby  excited 
to  increased  power  of  action  to  overcome  the  restraint;  he  applied, 
in  other  words,  the  principle  on  which  valvular  obstruction  leads 
to  hypertrophy.  But  the  analogy  does  not  hold  good.  As  re- 
marked by  Dr.  Stokes,  "  In  adhesion,  the  normal  condition  of  the 
muscle  is  interfered  with  and  the  contraction  diminished ;  while  in 
valvular  obstruction,  the  muscle  being  free  to  act,  increases  in 
power,  just  as  the  voluntary  muscles  do  when  trained  by  exercise." 
Atrophy  is  supposed  to  be  produced  as  an  effect  of  pressure,  which 
not  only  restrains  the  movements  of  the  heart,  somewhat  like  a 
bandage  applied  over  the  muscles  of  an  extremity,  but  by  inter- 
fering with  the  free  supply  of  blood  to  the  substance  of  the  organ. 
This  doctrine,  however  rational,  with  our  present  knowledge  must 

'  Guy's  Hospital  Reports,  vol.  vii. 


366  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

be  regarded  as  hypothetical ;  and,  as  a  matter  of  observation, 
enlargement  is  much  oftener  found  associated  with  pericardial 
adhesions  than  an  abnormal  diminution  of  the  volume  of  the  heart. 
Dr.  Kennedy  found  evidence  of  atrophy  in  only  five  of  the  ninety 
cases  analyzed  by  him.  True  atrophy,  i.  e.,  in  which  the  organ  is 
reduced  in  volume,  as  is  well  known,  is  one  of  the  rarest  of  cardiac 
lesions. 

In  conclusion,  while  it  is  not  to  be  denied  that  pericardial 
adhesions  do  contribute  to  enlargement  of  the  heart  in  a  certain 
proportion  of  cases,  nor  that  they  may  also,  in  rare  instances,  tend 
to  an  opposite  result,  they  exist  not  infrequently  for  a  long  period 
without  being  followed  by  any  appreciable  morbid  condition,  and 
their  tendency  to  the  production  of  either  organic  change  or  func- 
tional disturbance  is  vastly  less  than  w\as  supposed  by  Hope. 
With  this  general  view  of  the  effects  upon  the  heart  and  circula- 
tion, the  remote  consequences  of  pericarditis,  so  far  as  the  pericar- 
dium is  concerned,  need  not  occasion  much  apprehension.  It  is 
not  improbable  that  obliteration  of  the  pericardial  sac  after  acute 
pericarditis  is,  in  some  sense,  a  conservative  result,  preventing,  in 
some  instances,  persistence  of  the  inflammation  in  a  chronic  form. 
And  it  is  highly  probable  that  when  pericarditis  is  followed  by 
cardiac  enlargement,  exclusive  of  the  cases  in  which  valvular 
lesions  coexist,  the  enlargement  is  due  more  to  the  condition  of  the 
muscular  substance  of  the  heart,  produced  directly  by  the  inflam- 
mation, than  to  the  effect  of  the  adhesions.  Assuming  this  to  be 
the  view  most  consistent  with  our  present  knowledge,  its  practical 
importance,  as  regards  its  bearing  on  the  prognosis  and  manage- 
ment after  recovery  from  pericarditis,  is  sufficiently  obvious. 

How  is  the  existence  of  pericardial  adhesions  to  be  ascertained  during 

life? 

If  it  be  true  that  adhesions  may  remain  innocuous  for  an 
indefinite  period,  and  that  they  rarely,  if  ever,  of  themselves  give 
rise  to  serious  consequences,  the  importance  of  ascertaining  their 
existence  during  life  is  less  than  it  Avould  be  were  their  eflects  on 
the  heart  and  circulation  more  important.  Assuming  the  correct- 
ness of  the  general  view  of  these  effects  which  has  been  presented, 
I  shall  not  dwell  long  on  the  present  division  of  the  subject. 

Symptoms  referable  to  the  heart  and  circulation  are  not  distinct- 
ive of  adhesions.     Whatever  evidence  is  available  must  be  derived 


DIAGNOSIS    OF    PERICAEDIAL    ADHESIONS.  867 

from  physical  signs.  The  diagnosis  cannot  always  be  made  with 
positiveness ;  but,  in  a  certain  proportion  of  cases,  the  signs  may  be 
relied  upon  with  much  confidence,  especially  if  the  previous  history 
render  it  highly  probable  that  pericarditis  has  existed  at  a  period 
more  or  less  remote.  The  diagnostic  points  furnished  by  explora- 
tion require  that  the  adhesions  shall  be  nearly  or  quite  universal, 
and  they  are  more  marked  when,  in  addition  to  union  of  the  peri- 
cardial surfaces,  there  exists  firm  adhesion  of  the  exterior  of  the 
pericardium  to  the  parietes  of  the  chest. 

Percussion  shows  that  the  heart  is  in  contact  with  the  chest  over 
a  larger  space  than  normal ;  in  other  words,  the  area  of  the  super- 
ficial cardiac  region  is  enlarged.  But  as  this  occurs  whenever  the 
heart  is  increased  in  volume,  alone,  it  is  not  distinctive.  Another 
sign  obtained  by  percussion  is  significant.  It  is,  persistence  of  the 
dulness  within  the  same  area  in  different  positions  of  the  body,  and 
when  the  patient  takes  a  deep  inspiration.  This  shows  that  the 
heart  is  fixed,  and  that  external  adhesions  prevent  the  lung  from 
overlapping  the  organ,  even  when  expanded  by  a  forced  effort. 

Auscultation  concurs  with  percussion  in  showing  that  the  lungs 
do  not  extend  over  the  heart  on  a  full  inspiration,  provided  the 
pericardium  be  united  to  the  chest  by  pleuritic  adhesions.  This 
method  of  exploration  furnishes  no  other  diagnostic  points.  Clini- 
cal observation  has  not  established  any  peculiar  modifications  of 
the  heart-sounds.  On  theoretical  ground,  it  is  probable  that  the 
element  of  impulsion  in  the  first  sound  is  weakened,  but  the 
variations  in  this  respect  in  health  and  disease  are  such  as  to 
render  this  alteration  of  slight  import. 

Palpation  furnishes  important  signs.  The  apex-beat  is  frequently 
suppressed.  It  is  not  true  that  it  is  invariably  wanting,  even  when 
universal  and  close  adhesions  exist.  And,  on  the  other  hand,  the 
apex-beat  is  not  only  suppressed  in  connection  with  different  forms 
of  disease,  but  it  is  not  felt  in  all  healthy  persons.  Alone,  absence 
of  the  beat  is  by  no  means  distinctive,  but  it  is  significant  when 
taken  in  oonnection  with  other  signs.  Its  suppression  is  accounted 
for  by  the  fact  that  pericardial  adhesions  interfere  with  the  elonga- 
tion and  locomotion  of  the  heart's  apex,  more  particularly  the  latter. 
When  not  suppressed,  the  beat  may  be  felt  higher  than  its  normal 
position,  viz.,  in  the  fourth  instead  of  the  fifth  interspace,  while  the 
body  is  in  a  vertical  position.  This  change  of  position,  in  connec- 
tion with  other  signs,  has  considerable  significance.     If,  however, 


368  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

the  lieart  be  much  enlarged,  the  apex  may  be  lowered,  notwith- 
standing the  adhesions. 

Impulses  may  be  felt  in  the  intercostal  spaces  above  the  point  of 
apex-beat,  but  this  is  not  infrequently  observed  in  cases  of  simple 
enlargement.  Successive  movements  in  different  intercostal  spaces, 
presenting  an  appearance  of  undulation,  can  hardly  be  considered 
as  a  sign  of  adhesions,  if  enlargement  be  present. 

The  apex,-beat  undergoes  but  little  alteration  in  its  position  with 
change  of  posture.  This  sign  has  considerable  significance.  In 
health,  the  position  of  the  beat  is  removed  to  the  left,  from  half  an 
inch  to  an  inch,  by  changing  the  posture  from  that  on  the  back  to 
that  on  the  left  side.  Pericardial  and  pleuritic  adhesions  prevent 
this  lateral  movement  of  the  heart's  apex.  I  have  observed,  in  a 
patient  supposed  to  have  adhesions,  that  the  impulse  not  only  re- 
mained in  the  same  position,  but  retained  the  same  force,  the  patient 
lying  on  the  right  side,  as  when  lying  on  the  back.  In  health,  the 
impulse  is  either  moved  to  the  right  by  this  change  of  posture,  or, 
more  frequently,  lost.  Another  point  pertaining  to  the  apex-beat 
is  its  preserving  the  same  position  with  the  difierent  acts  of  respira- 
tion. It  is  not  depressed  by  a  forcible  inspiration,  nor  raised  by  a 
forcible  expiration,  to  the  same  extent  as  in  health. 

A  jogging  or  tumbling  motion  of  the  heart,  as  perceived  by  the 
hand,  was  considered  by  Hope  as  a  distinctive  sign.  But  violent 
and  disturbed  rhythmical  action  is  not  only  observed  in  cases  of 
enlargement  and  of  merely  functional  disorder,  but  tranquil  regu- 
larity of  the  heart's  movements  is  perfectly  compatible  with  uni- 
versal and  close  adhesions.  Nor  is  a  sensation,  communicated  to 
the  hand,  as  if  the  heart  were  restrained,  or  were  struggling  against 
an  obstacle,  of  which  Bouillaud  speaks,  to  be  relied  upon.^  Such 
a  sensation  must  involve  a  preconceived  idea  that  adhesions  exist. 
Inspection  furnishes  signs  which  are  the  most  distinctive,  viz., 
retraction  of  the  intercostal  spaces,  and  depression  of  the  epigas- 
trium to  the  left  of  the  xiphoid  cartilage,  occurring  synchronously 
with  the  ventricular  systole.  The  depression  movement  of  the  epi- 
gastrium is  due  to  the  attachment  of  the  base  of  the  pericardium  to 
the  cordiform  tendon  of  the  diaphragm ;  the  retraction  movement 
of  the  intercostal  spaces  is  caused  by  the  drawing  in  of  these  spaces 
when  the  ventricles  contract,  and  is  most  marked  when  the  peri- 

'  "On  sent  a  la  main  que  le  jeu  du  cceur  est  embarrasse,  difficile,  etc."    Lemons 
Cliniques,  1853. 


PERICARDIAL    ADHESIONS.  869 

cardium  is  attached  to  the  parietes  of  the  chest.  One  or  two,  and 
possibly  three,  of  the  intercostal  spaces  may  present  retraction,  and 
in  some  instances  the  ribs  are  also  retracted.  Depression  of  the 
epigastrium  may  be  present  alone,  or  associated  with  intercostal 
retraction.  In  some  instances  the  xiphoid  cartilage,  and  even  the 
lower  portion  of  the  sternum,  is  drawn  inward,  apparently  with 
considerable  force.  These  signs,  when  present  in  a  marked  degree, 
and  especially  in  combination,  are  highly  distinctive. 

To  recapitulate  the  physical  signs  denoting  pericardial  adhesions, 
they  are  as  follows :  the  area  of  prsecordial  dulness  on  percussion 
remaining  unaltered  in  different  positions  of  the  body,  and  not 
affected  by  a  deep  inspiration:  the  limits  of  the  respiratory  murmur 
not  affected  by  a  deep  inspiration;  the  apex-beat  often  suppressed, 
and,  if  not  suppressed,  often  raised  above  its  normal  position ;  the 
apex-beat,  if  felt,  unaffected,  or  affected  but  slightly,  by  changes  of 
posture  from  the  back  to  either  side,  and  by  forcible  inspiration  or 
expiration;  retraction  of  one  or  more  intercostal  spaces,  together 
with  the  ribs  in  some  cases,  and  depression  of  the  epigastrium 
synchronously  with  the  ventricular  systole. 

These  signs  strengthen  each  other  by  combination.  The  more 
are  combined,  the  greater  the  significance  of  each.  Not  one,  how- 
ever, is  constant,  and  all  may  be  wanting  in  cases  of  pericardial 
adhesions.  They  are  rarely,  if  ever,  marked,  unless  the  pericardium 
be  attached  to  the  thoracic  walls  by  pleuritic  adhesions,  and  these 
do  not  always  coexist  with  union  of  the  pericardial  surfaces.  A 
positive  diagnosis,  therefore,  is  only  practicable  in  a  certain  propor- 
tion of  cases.  If  it  be  known  that  a  patient  has  had,  at  some  past 
period,  an  attack  of  pericarditis,  this  fact  renders  less  physical 
evidence  necessary  for  the  diagnosis  than  if  the  previous  history 
contained  no  information  with  respect  to  that  point.  The  fact  of 
the  patient  having  had  acute  rheumatism  acds  weight  to  the  con- 
clusion drawn  from  the  physical  signs.  Contraction  of  the  chest, 
limited  to  the  prcecordia.  is  also  a  collateral  point  of  evidence,  as 
showing  that  pericarditis  has  existed. 


2i 


CHAPTER    VIII. 

INFLAMMATORY  AFFECTIONS   OF  THE  HEART. 
ENDOCARDITIS.     MYOCARDITIS. 

Endocarditis — Definition — Anatomical  characters — Pathological  relations  and  causation — 
Syniptoms — Physical  signs — Diagnosis — Prognosis — Treatment — Myocarditis. 


ENDOCARDITIS. 


Inflammation  of  the  endocardium,  the  membrane  which  lines  the 
cavities  of  the  heart  and  is  duplicated  to  cover  the  valves,  is  called 
endocarditis.  This  name  originated  with  Bouillaud,  who  was  the 
first  to  recognize  clearly  the  occurrence  of  inflammation  in  this 
situation.  Eecent  clinical  researches  have  shown  that  this  disease, 
the  nosological  existence  of  which  dates  from  a  little  more  than  a 
quarter  of  a  century  ago,  is  by  no  means  infrequent.  It  occurs  as 
a  complication  of  acute  rheumatism,  in  a  large  proportion  of  cases. 
The  knowledge  of  its  frequent  coexistence  with  this  affection,  is 
one  of  the  most  important  of  the  developments  of  modern  medicine. 
The  remote  effects  of  endocarditis,  as  involved  in  the  valvular 
lesions  v.rhich  have  been  considered  in  a  former  chapter,  invest  the 
disease  with  much  importance.  Inflammation  here,  as  in  other 
situations,  may  be  acute,  subacute,  and  chronic ;  but  it  is  hardly 
practicable  to  make  these  distinctions,  clinically,  and  hence  it  suffi- 
ces to  consider  the  subject  under  the  head,  simply,  of  endocarditis. 
In  the  consideration  of  this  subject,  the  same  divisions  will  be 
adopted  as  in  treating  of  acute  pericarditis,  viz.,  the  anatomical  cha- 
racters of  the  disease,  its  pathological  relations  and  causation,  its 
symptomatic  phenomena,  its  physical  signs,  the  diagnosis,  the  prog- 
nosis, and  the  treatment.  These  divisions  will  be  taken  up  in  the 
order  in  which  they  have  just  been  named. 


ANATOMICAL    CHARACTERS    OF    ENDOCARDITIS.         371 


Anatomical  Characters  of  Endocarditis. 

Endocarditis  is  seated,  in  the  vast  majority  of  cases,  in  the  cavi- 
ties of  the  left  side  of  the  beart.  The  lining  membrane  of  the  right 
auricle  and  ventricle  is  rarely  inflamed.  When  inflammation 
does  exist  in  the  cavities  of  the  right  side,  it  is  also  present, 
almost  invariably,  in  those  of  the  left  side.  The  instances  of  endo- 
carditis limited  to  the  right  cavities,  are  exceedingly  rare.  All 
portions  of  the  endocardial  membrane  are  not  equally  subject  to 
inflammation.  The  portions  covering  the  valves,  and  lining  the 
orifices  are  especially  prone  to  become  inflamed.  Endocarditis  is 
generally  limited  to  these  situations.  The  membrane  here  is  most 
exposed  to  the  action  of  the  blood-currents ;  the  valvular  portion 
is  in  constant  motion,  and  considerable  tension,  or  stretching,  must 
take  place  with  each  ventricular  systole.  But  another,  and  perhaps 
a  stronger,  reason  for  the  limitation  of  inflammation  to  these  situa- 
tions, is  derived  from  the  fact  that  the  membrane  is  here  under- 
laid by  fibrous  tissue,  while  in  other  portions  it  is  in  close 
proximity  to  the  muscular  walls  of  the  heart.  The  rule  as  regards 
the  greater  liability  of  the  left  side  of  the  heart,  to  endocardial  in- 
flammation, is  applicable  after  birth,  but  probably  does  not  hold 
good  during  intra-uterine  life.  There  are  grounds  for  the  belief 
that  the  foetus  in  utero  is  subject  to  endocarditis,  and  that  at  this 
period  the  inflammation  is  generally  seated  in  the  right  side  of 
the  heart.  The  malformations  which  have  been  considered  in  a 
previous  chapter,  are  in  a  measure  thus  accounted  for. 

Opportunities  for  inspecting  the  morbid  appearances  during  the 
progress  of  endocarditis,  are  not  often  presented.  The  disease  very 
rarely  proves  fatal.  It  is  not  the  immediate  danger,  but  the  remote 
consequences  which  render  it  a  formidable  al^'ection.  The  anatomi- 
cal characters  which  have  been  observed  in  the  occasional  instances 
in  which  death  has  occurred  when  inflammation  existed,  embrace 
here,  as  in  other  situations,  redness  from  vascular  injection,  altera- 
tions in  the  membrane  itself,  and  the  presence  of  inflammatory  pro- 
ducts. 

Eedness  due  to  endocarditis  is  caused  by  injection  of  the  vessels 
which  ramify  in  the  areolar  tissue  beneath  the  membrane.  It  is 
not  always  found  when  inflammation  undoubtedly  existed  at  the 
time  of  death.  It  may  disappear  as  a  post-mortem  change.  On  the 
other  hand,  mere  redness  is  by  no  means  adequate  evidence  of  the 


372  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

existence  of  inflammation.  It  is  often  observed  in  the  cavities  of 
the  heart,  and  in  the  large  vessels,  as  an  effect  of  the  imbibition  of 
hsematin  dissolved  out  of  the  red  globules  of  the  blood  which  these 
cavities  and  vessels  contain  after  death.  Under  these  circumstances, 
it  is  a  cadaveric  staining  of  the  membrane,  and  is  an  effect  of  the 
decomposition  of  the  blood.  It  is  observed  frequently  in  post- 
mortem examinations,  more  especially  when  these  are  made  two  or 
three  days  after  death,  or  when  the  warmth  of  the  weather  favors 
putrefactive  changes  ;  and  it  is  a  post-mortem  condition  found  after 
certain  diseases  in  which  the  blood  undergoes  notable  changes 
prior  to  death.  The  redness  from  imbibition  is  distinguished  from 
that  due  to  inflammation,  by  the  following  points  of  difference: 
It  is  not  an  arborescent,  but  an  uniform  redness,  and  when 
examined  with  a  lens,  injected  vessels  are  not  visible.  It  is  deeper 
or  of  a  darker  color  than  inflammatory  redness.  It  is  more  likely 
to  be  observed  in  the  right  than  in  the  left  side  of  the  heart,  a 
larger  quantity  of  blood  usually  remaining  in  the  right  cavities 
after  death.  It  is  not  limited  to  the  valves  or  orifices,  and  usually 
extends  into  the  arteries  where  it  is  more  conspicuous  than  in  the 
cardiac  cavities.  The  redness  is  most  marked  in  the  dependent 
parts  of  the  heart  and  vessels.  It  is  readily  removed  by  macera- 
tion, which  is  not  true  of  inflammatory  redness.  Exclusive  of  the 
discoloration,  the  membrane  preserves  its  natural  appearance ;  it  is 
firm  and  polished  as  in  its  normal  condition,  and  does  not  present 
any  of  the  inflammatory  products.  Whatever  may  be  the 
characters  pertaining  to  redness,  if  the  membrane  be  normal  in  all 
other  respects,  and  the  products  of  inflammation  wanting,  the  evi- 
dence of  the  inflammatory  state  is  insufficient. 

Anatomical  changes  in  the  membrane  are  much  more  distinctive 
of  inflammation  than  redness.  These  changes  are,  loss  of  the 
transparent,  smooth,  polished  appearance  which  this  structure 
presents  in  a  healthy  state,  instead  of  which  it  becomes  opaque, 
rough,  velvety,  and  felt-like;  more  or  less  swelling  and  softening; 
brittleness  of  the  subjacent  areolar  tissue,  in  consequence  of  which 
it  is  more  easily  detached  than  in  its  normal  condition.  Anatomical 
changes  are  often  found  which  are  due  to  ancient  inflammation,  and 
to  morbid  processes  not  inflammatory,  such  as  atheromatous  deposit 
and  hypertrophy  of  the  endocardium.  These  changes  are,  of 
course,  to  be  distinguished  from  those  which  denote  endocarditis 
existing  at  the  time  of  death. 

Other  characters  relate  to  the  products  of  inflammation.     As 


ANATOMICAL    CHARACTERS    OF    ENDOCARDITIS.         378 

regards  these,  the  endocardium,  although  resembling  in  structure 
serous  membranes,  differs  from  the  latter  in  not  being  a  shut  sac, 
within  which  the  inflammatory  products  are  collected  and  retained 
for  a  greater  or  less  period.  Morbid  deposits  are  liable  to  be 
detached,  washed  away  by  the  currents  of  blood,  and  carried  along 
with  the  circulation.  The  endocardium  differs  from  serous  mem- 
branes in  another  important  point,  viz.,  it  is  in  contact  with  the 
blood  itself;  and  while  this  fluid,  in  motion,  detaches  and  removes 
deposits,  it  may  also  furnish  them  by  yielding  a  portion  of  its 
fibrin  which  undergoes  coagulation. 

The  products  of  inflammation  in  endocarditis  may  be  derived. 
from  two  sources,  viz.,  the  coagulation  of  fibrin,  just  alluded  to, 
and  the  exudation  of  lymph  occurring  here  precisely  as  in  serous 
inflammations.  In  the  one  case  they  are  derived  from  the  blood 
within  the  cavities  of  the  heart,  and  in  the  other  case,  from  the 
blood  in  the  vessels  situated  in  the  areolar  tissue  beneath  the 
endocardium.  The  extent  to  which  deposits  found  after  death  are 
derived  from  these  two  sources,  respectively,  has  given  rise  to 
much  discussion  among  pathologists.  The  question  is  one  not 
easily  settled  with  exactness.  The  most  rational  view,  with  our 
present  knowledge,  is,  that  both  sources  are  generally  involved, 
and  in  different  proportions  in  different  cases.  Exudation  of 
lymph  from  the  blood  contained  within  the  vessels,  doubtless  takes 
place  here,  as  in  analogous  structures  when  inflamed.  The  deposit 
from  this  source  occurs  on  the  free  surface  of  the  membrane,  and 
beneath  the  membrane.  If  not  detached  and  washed  away  by  the 
blood-currents,  the  lymph  exuded  on  the  free  surface  remains 
attached  to  the  membrane.  It  is  not  infrequently  found  adherent 
in  membranous-like  layers  as  in  cases  of  pericarditis  or  pleuritis, 
but  not  in  the  same  abundance.  The  roughness  produced  by  the 
exudation  of  lymph  or  the  alterations  of  the  membrane,  attracts, 
as  it  were,  the  fibrin  from  the  blood,  and  leads  to  its  precipitation 
in  a  coagulated  state.  The  deposit  is  thus  augmented  from  this 
second  source.  The  lymph  is  equivalent  to  a  foreign  substance, 
and  becomes  coated  with  fibrin,  like  the  threads  passed  through 
arteries  in  Dr.  Simon's  experiments.  An  increased  proportion  of 
fibrin  in  the  blood,  which  characterizes  in  a  marked  degree  acute 
rheumatism,  probably  favors  the  deposit  from  the  latter  source. 
This  twofold  origin  of  the  products  of  inflammation  is  important 
in  its  bearing  on  the  treatment  of  endocarditis. 

The  inflammation  affecting  especially  the  valves  and  orifices  of 


374  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

the  left  side  of  the  heart,  morbid  deposits,  as  well  as  other  anato- 
mical changes,  are  usually  found  in  these  situations.  The  deposits 
consist  of  lymph  upon  and  beneath  the  endocardium,  rendering  the 
membrane  opaque  and  apparently  thickened,  and  forming  vegeta- 
tions which  are  composed  partly  of  lymph,  and  in  part  of  coagulated 
fibrin.  The  latter  are  found  more  especially  either  at  the  base  or 
free  extremities  of  the  valves,  and  they  are  most  apt  to  occur  on  the 
surface  of  the  valves  exposed  to  the  direct  current  of  blood,  i  e., 
on  the  auricular  aspect  of  the  mitral,  and  on  the  ventricular  aspect 
of  the  aortic,  valve.  Deposits  consisting  of  lymph  frequently  as- 
sume the  form  of  small  granular  masses  or  beads,  varying  in  size 
from  that  of  a  pin's  head  to  a  millet-seed,  studding  the  margins  of 
the  curtains  of  the  mitral  valve  and  the  tendinous  cords,  and  fring- 
ing the  crescentic  extremity  of  the  fibrous  portion  of  the  segments 
of  the  valve  of  the  aorta.  These  deposits  are  removed  with  slight 
force  after  recent  endocarditis,  and  the  surface  beneath  may  be 
roughened,  excoriated,  and  thickened,  or  changes  in  the  appearance 
of  the  membrane  may  not  be  marked.  The  deposits,  however,  are 
often  larger,  forming  excrescences  of  the  size  of  a  pea,  and  even 
considerably  larger  than  this.  These  consist  usually  of  the  smaller 
bead-like  granulations  of  lymph,  which  have  become  coated  by  the 
accretion  of  fibrin.  The  latter  constitutes  the  larger  portion  of 
their  substance. 

The  exudation  of  lymph  is  unequivocal  evidence  of  the  existence 
of  endocarditis.  The  deposit  of  fibrin  has  not  this  significance  in 
an  equal  degree.  The  latter,  according  to  the  views  of  some  dis- 
tinguished pathologists,*  may  occur  solely  as  a  result  of  an  excess 
in  the  fibrinous  constituent  of  the  blood,  or  of  some  change  in  con- 
sequence of  which  the  blood  does  not  retain  the  fibrin  in  a  liquid 
form,  as  in  health.  The  presence,  therefore,  of  deposits  in  the  form 
of  vegetations  is  not  positive  proof  that  endocarditis  has  existed, 
unless  they  consist,  in  part  at  least,  of  exuded  lymph.  The  appear- 
ances of  the  deposits  do  not  always  suffice  for  the  discrimination 
between  fibrin  and  lymph,  and  hence  the  deposits  are  not  to  be  con- 
sidered as  anatomical  characters  which,  alone,  are  absolutely  reliable. 
As  criteria  of  inflammation,  they  are  inferior  to  the  changes  which 
the  endocardial  membrane  presents.  But  the  latter,  in  general, 
coexist,  to  a  greater  or  less  extent,  with  inflammatory  deposits. 
The  deposit  of  fibrin  in  cases  of  old  valvular  lesions,  and  when  the 

'  E.  g.,  Rokitanskj,  vide  Path.  Anat. ;  Dr.  Fuller,  vide  work  ou  rheumatism. 


ANATOMICAL    CHARACTERS    OF    ENDOCARDITIS.         375 

endocardial  membrane  has  undergone  changes  incident  to  atheroma 
or  other  processes  not  inflammatory,  does  not  constitute  evidence  of 
recent  endocarditis.  Eoughness  of  the  membrane,  irrespective  of 
existing  inflammation,  suffices  to  determine  this  deposit,  especially 
when  the  condition  of  the  blood  is  such  as  to  favor  the  separation 
and  coagulation  of  fibrin. 

Other  morbid  changes  which  may  occur  during  the  progress  of 
endocarditis  are,  loss  of  substance,  or  destruction  of  portions  of  the 
membrane,  by  ulceration  or  erosion ;  perforation  of  the  valves ; 
lacerations ;  and,  according  to  Bouillaud,  occasionally  gangrene. 
These  are  rare  occurrences  as  immediate  results  of  the  inflamma- 
tory processes.  Lacerations  and  erosions  are  the  least  infrequent. 
Adhesion  of  the  valves  to  each  other,  to  the  walls  of  the  heart,  or, 
in  the  case  of  the  semilunar  valves,  to  the  inner  surface  of  the 
artery,  are  to  be  included  among  the  comparatively  rare  anatomical 
changes  incident  to  recent  endocarditis.  Other  effects  are  true 
morbid  growths,  as  distinguished  from  the  vegetations  which  con- 
sist of  either  lymph  or  fibrin,  or  both  combined. 

The  opportunity  of  inspecting  the  morbid  appearances  during  the 
difierent  stages  of  the  progress  of  endocarditis,  as  already  stated,  is 
rarely  presented,  inasmuch  as  the  disease  seldom  proves  fatal.  For 
this  reason  the  appearances  found  after  death  in  the  experiments 
made  by  Dr.  Richardson,  in  which  endocarditis  was  artificially 
induced  in  inferior  animals  by  the  introduction  of  lactic  acid  into 
the  blood,  are  of  much  interest  and  value.'  In  sixteen  experiments 
on  dogs,  cats,  and  rabbits,  endocarditis  was  invariably  produced 
when  a  certain  quantity  of  lactic  acid,  largely  diluted,  was  injected 
into  the  peritoneal  cavity.  If  the  animals  died  or  were  killed  at  a 
period  when  the  symptoms  denoted  commencing  inflammation,  the 
endocardial  membrane  presented  a  brilliant  vermilion  color;  it  had 
a  velvety  or  villous  appearance,  and  beads  of  lymph  or  fibrin  were 
abundant.  At  a  somewhat  later,  but  still  early,  period  the  auriculo- 
ventricular  valve  became  thickened  and  oedematous.  The  writer 
says :  "  I  have  seen  the  segments  of  the  tricuspid  valve  fixed  in 
this  swollen  condition,  resembling  each  an  injected  uvula,  and  lying 
so  close  to  each  other  that,  when  the  heart  was  contracting,  they 
must  have  cushioned  against  each  other,  thus  fulfilling  their  office 
of  preventing  regurgitation  passively,  i.e.^  without  tension  or  move- 

'  An  Experimental  Inquiry  on  Endocarditis,  by  the  Synthetical  Method.  By 
Benjamin  W.  Richardson,  M.  D.,  etc.  Contained  in  Vir(j'inia  Medical  Journal, 
March,  1859.     See  also  appendix  to  Prize  Essay,  London,  1858. 


376  INFLAMMATORY   AFFECTIONS    OF    THE    HEART. 

ment.  In  this  oedematous  stage,  if  the  valve  be  pricked  with  a 
needle,  a  clear  white  lymphy  fluid  exudes,  and  by  frerj^uent  pricking 
the  valve  structure,  emptied  of  its  effusion,  collapses  and  assumes  a 
flaccid  condition."  At  a  later  period  "the  valves  remained  thick- 
ened, but  the  red  color  and  oedematous  state  were  both  reduced. 
Beneath  the  endocardial  surface  of  the  valve  there  was  a  paleness 
as  from  coagulated  effused  lymph.  If  the  needle  be  applied  now, 
there  is  no  exudation;  the  valve  has  some  limited  play,  unless  it  is 
bound  down  by  adhesion,  and  its  structure  is  firm.  Beads  which 
generally  fringe  the  margin  of  the  valves  all  around,  from  being 
oedematous  prominences  in  the  earlier  stages,  are  pearly  looking, 
and  are  moderately  firm."  Still  later,  the  writer  describes  the 
valves  as  shrunken,  having  regained  imperfect  play,  but  still  thick- 
ened and  unyielding.  It  is  probable  that  this  account  of  the  mor- 
bid appearances  in  inferior  animals  may  be  applied  analogically  to 
endocarditis  in  man,  during  periods  of  the  disease  when  the  anato- 
mical characters  can  be  studied  in  only  the  very  rare  instances  in 
which  a  fatal  result  takes  place,  and  when  a  sufficient  time  has 
not  elapsed  after  death  for  important  post  mortem  changes  to  have 
ensued.  These  experiments  will  be  again  referred  to  in  connection 
with  the  causation  of  endocarditis. 

A  point  observed  by  Dr.  Richardson  with  regard  to  the  situation 
of  the  anatomical  changes  in  artificially  induced  endocarditis  may 
be  here  mentioned.  These  changes  were  mostly  confined  to  the 
auriculo- ventricular  valves.  He  states  :  "A  very  slight  thickening, 
not  sufficient  at  any  time  to  interfere  seriously  with  their  duties,  is 
all  I  have  ever  observed  in  the  semilunar  valves  on  either  side." 

The  remote  effects  of  endocarditis  are  vastly  more  serious  than 
the  immediate  anatomical  changes.  The  latter  lay  the  foundation 
of  the  various  valvular  lesions  which  were  considered  in  Chapter 
III.  These  lesions  are  slowly  induced  in  consequence  of  the 
presence  of  the  morbid  deposits,  their  progressive  increase  by 
accretion  from  the  precipitation  of  fibrin,  the  process  of  calcifica- 
tion, etc.,  together  with  the  softening,  friability,  and  sometimes 
solution  of  continuity  of  the  endocardium  and  the  subjacent  tissue. 
Insufficiency  of  the  valves  and  contraction  of  the  orifices  are 
ulterior  consequences,  giving  rise  to  enlargement  of  the  heart  and 
other  pathological  effects  which  have  been  treated  of  in  preceding 
chapters.  With  reference  to  their  eventuation  in  valvular  lesions 
involving  either  obstruction  or  regurgitation,  or  both,  the  imme- 
diate anatomical  changes  in  endocarditis  are  of  great  importance. 


ENDOCAKDITIS    IN   ACUTE    EHEUMATISM.  877 

In  a  very  large  proportion  of  cases,  valvular  lesions  owe  their 
origin  to  these  changes.  Hence,  a  person  attacked  with  endocar- 
ditis is  liable,  at  a  period  more  or  less  distant,  perhaps  after  many 
months  or  years,  to  fall  a  victim  to  organic  disease  of  the  heart. 
The  rapidity  and  extent  of  the  remote  effects  will  be  proportionate, 
other  things  being  equal,  to  the  amount  of  deposits  and  other 
changes  which  remain  after  the  endocardial  inflammation  has 
ceased.  In  this  respect  different  cases  doubtless  vary.  It  is  possi- 
ble for  the  fibrin  and  lymph  deposited  upon  the  free  surface  of  the 
membrane  to  be  gradually  washed  away  by  the  blood-currents,  the 
inflammatory  products  beneath  the  endocardium  removed  by  ab- 
sorption, and  the  normal  condition  of  the  valves  restored,  so  that 
no  ulterior  evils  follow  the  disease  at  any  period,  however  remote. 
This  happy  termination,  if  it  ever  occurs,  is  a  rare  exception  to  the 
general  rule. 


Pathological  Relations  and  Causation  of  Endocarditis. 

Endocarditis  resembles  pericarditis  in  the  infrequency  of  its 
occurrence  as  an  idiopathic  affection.  It  occurs,  however,  inde- 
pendently of  other  afl^ections,  oftener  perhaps  than  is  generally 
supposed,  its  latency  as  regards  symptoms  being  such  that  it  is  apt 
to  be  overlooked.  In  the  great  majority  of  the  cases  in  which  its 
existence  is  ascertained,  it  is  associated  with  acute  articular  rheu- 
matism. It  is  comparatively  a  very  rare  affection  as  occurring  in 
other  pathological  connections.  Eheumatic  endocarditis  is  suffi- 
ciently common  for  cases  to  fall  frequently  under  the  observation 
of  the  medical  practitioner.  It  is  perhaps  not  far  from  the  truth 
to  say  that,  in  a  case  of  acute  articular  rheumatism,  the  chances  are 
about  equal  that  the  endocardial  membrane  will  become  involved. 
Endocarditis  and  pericarditis  are  not  infrequently  associated  in 
cases  of  rheumatism.  The  combined  aft'ections  are  designated  endo- 
IDericarditis.  Rheumatic  pericarditis  very  rarely  exists  without 
endocarditis.  But  the  converse  of  this  statement  does  not  hold 
good ;  endocarditis  often  exists  without  being  associated  with  peri- 
carditis. The  statement  by  Hope  that  endocarditis  exists  without 
pericarditis  much  oftener  than  pericarditis  without  endocarditis  I 
believe  to  be  correct,  although  an  opposite  opinion  is  held  by  Dr. 
Stokes,  With  reference  to  the  frequency  of  endocarditis  in  acute 
rheumatism,  and  the  relative  proportion  of  cases  in  which  endocar- 


378 


INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 


ditis,  pericarditis,  and  endo-pericarditis,  respectively,  occur  in  the 
cases  of  rheumatism  with  cardiac  complication,  the  following  statis- 
tics may  be  cited :  Of  474  cases  collected  from  various  sources  and 
analyzed  by  Dr.  Fuller,  endocarditis  existed  in  214,  the  ratio  being 
as  1  to  every  2.25  cases.  These  cases  were  reported  by  four  differ- 
ent observers,  and  the  analysis  of  each  collection  gives  not  far  from 
the  same  ratio  as  when  they  are  analyzed  collectively.  Of  204 
cases  of  rheumatism  with  cardiac  complication  of  some  kind,  endo- 
carditis existed  in  138,  pericarditis  in  19,  and  endo-pericarditis  in 
38.  The  accuracy  of  these  statistics  is,  of  course,  based  on  the 
practicability  of  determining  the  coexistence  of  endocarditis  in 
cases  of  rheumatism,  and  there  are  certain  difficulties  in  the  way  of 
arriving  at  a  positive  conclusion  with  respect  to  this  point  in  some 
cases,  as  will  appear  in  connection  with  the  subject  of  the  diagnosis. 

The  portion  of  the  endocardial  membrane  which  covers  the 
mitral  valve  is  affected  oftener  and  to  a  greater  extent  than  the 
portion  which  is  in  relation  with  the  aortic  valves,  in  cases  of 
rheumatic  endocarditis.  This  fact  is  shown  by  the  signs  during 
life  which  indicate  the  mitral  valve  as  the  seat  of  disease,  and  by 
the  larger  proportion  of  instances  in  which  mitral  valvular  lesions 
are  observed  in  the  cases  in  which  organic  affections  of  the  heart 
are  traceable  to  an  attack  of  rheumatism.  The  anatomical  charac- 
ters of  endocarditis  artificially  induced  in  inferior  animals,  in  Dr. 
Richardson's  experiments,  as  has  been  stated,  were  mostly  limited 
to  the  auriculo-ventricular  valves. 

What  is  the  nature  of  the  pathological  relation  existing  between 
endocarditis  and  acute  rheumatism  ?  The  remarks  in  connection 
with  a  similar  question  as  applied  to  pericarditis  are  here  equally 
applicable.  The  endocardial  inflammation  is  not  developed  as  a 
metastasis  of  the  articular  affection.  The  former  proceeds  from  the 
same  morbid  condition  which  determines  the  latter.  Both  are 
effects  of  a  common  internal  cause.  The  affection  of  the  joints  is 
not  lessened  by  the  occurrence  of  endocarditis.  Nor  does  the 
affection  of  the  joints  always  precede  the  development  of  the  endo- 
cardial inflammation.  The  latter  occasionally  takes  precedence. 
Clinical  observation  appears  to  show  that  the  liability  to  endocar- 
ditis is  in  proportion  to  the  acuteness  of  the  rheumatism ;  yet  it  is 
to  be  borne  in  mind  that  the  mildest  cases  of  rheumatism  are  not 
exempt  from  this  liability.  Endocarditis  may  be  developed  at  any 
period  during  the  career  of  acute  rheumatism  ;  but  the  statistics  of 
Dr.  Fuller  go  to  show  that  the  liability  is  greatest  between  the 


ENDOCAEDITIS    IN    BRIGHT's    DISEASE.  379 

sixth  and  twentieth  days  of  the  disease.  The  influence  of  youth  in 
the  development  of  rheumatic  endocarditis  does  not  appear  to  be 
so  marked  as  with  respect  to  pericarditis. 

Endocarditis,  as  well  as  pericarditis,  is  one  of  the  secondary 
inflammations  liable  to  become  developed  in  connection  with 
Bright's  disease.  Of  39  fatal  cases  of  recent  endocarditis  analyzed 
with  reference  to  this  point  by  Dr.  T.  K.  Chambers,^  it  was  referable 
to  urtemia  from  Bright's  disease  in  12.  In  the  same  collection  of 
cases,  the  affection  was  connected  with  acute  rheumatism  in  only  9. 
These  figures  show  a  larger  proportion  of  fatal  cases  from  urasmic 
than  from  rheumatic  endocarditis.  The  same,  it  has  been  seen,  is 
also  true  with  regard  to  pericarditis.  The  fact  is  owing  to  the 
greater  fatality  of  endocarditis,  as  well  as  pericarditis,  when  asso- 
ciated with  Bright's  disease.  The  latter  affection,  existing  to  an 
extent  to  induce  inflammation  of  any  of  the  important  organs  of 
the  body,  generally  proves  fatal.  On  the  other  hand,  acute  rheu- 
matism complicated  with  cardiac  disease,  very  rarely  ends  fatally. 
The  difference  in  fatality  between  the  two  affections  thus  accounts 
for  the  preponderance  of  fatal  cases  of  endocarditis  with  Bright's 
disease,  while  the  proportion  of  instances  in  which  endocarditis  is 
associated  with  acute  rheumatism  is  vastly  greater. 

As  regards  the  pathological  relation  existing  between  endocar- 
ditis and  Bright's  disease,  the  remarks  made  with  respect  to  peri- 
carditis are  equally  applicable.  It  is  most  consistent  with  our 
present  knowledge  to  attribute  the  development  of  the  former,  as 
well  as  the  latter,  to  the  accumulation  of  urinary  principles  in  the 
blood.  The  analogy  of  structure  between  the  endocardium  and 
serous  membranes,  explains  the  liability  of  the  former  to  become 
inflamed  under  the  same  conditions  which  occasion  inflammation 
of  the  latter. 

It  is  stated  that  in  non-rheumatic  endocarditis,  the  aortic  valves 
are  more  likely  to  be  the  seat  of  inflammation  than  the  mitral,  the 
reverse  being  true,  as  has  been  seen,  of  rheumatic  endocarditis.' 
But  in  a  pretty  large  proportion  of  instances,  the  endocardium  in 
both  situations  is  affected,  whatever  may  be  the  pathological  con- 
nection of  the  disease. 

Endocarditis  and  pericarditis,  as  already  stated,  are  frequently 
associated.  This  combination  existed  in  38  of  the  204:  cases 
analyzed  by  Dr.  Fuller.     Clinical  observation  shows  that  either 

'  Op.  cit.  -  Bellmgham,  op.  cit.,  part  ii.  p.  348. 


380         INFLAMMATORY   AFFECTIONS    OF    THE    nEART. 

affection  may  take  precedence  of  the  other  in  point  of  time.  Peri- 
carditis, in  fact,  rarely  exists  without  the  coexistence  of  endocar- 
ditis. Hence,  it  may  seem  reasonable  to  infer  that  inflammation  in 
either  situation  tends  to  develop  it  in  the  other,  and,  especially, 
that  pericarditis  leads  to  the  development  of  endocarditis.  It  is 
doubtful,  however,  whether  any  causative  relation  exists  between 
the  two  affections.  When  associated,  they  are  probably  effects  of 
a  common  pathological  condition.  This  condition,  in  the  great 
majority  of  cases,  is  either  rheumatic  poisoning,  or  uriemia,  but 
much  oftener  the  former  than  the  latter,  clinical  experience  showing 
that  endo-pericarditis  is  more  frequently  associated  with  rheumatism 
than  with  Bright's  disease. 

Endocarditis  is  sometimes  associated  with  inflammation  of  the 
pulmonary  structures — pleurisy  or  pneumonia.  It  is  less  frequently 
associated  with  these  affections  than  pericarditis.  The  difference, 
as  regards  rheumatic  endocarditis  and  pericarditis,  is  shown  by  the 
following  statistics  by  Dr.  Fuller:'  Pulmonary  inflammation,  of 
some  kind,  existed  in  only  8  of  80  cases  (a  ratio  of  1  to  10)  of 
acute  rheumatism  complicated  with  endocarditis.  It  existed  in  7 
of  12  cases  (1  to  1.7)  of  acute  rheumatism  complicated  with  peri- 
carditis; and  in  19  of  27  cases  (1  to  1.4)  in  which  endo-pericarditis 
was  a  complication.  Pulmonary  inflammation,  however,  exists 
oftener  in  cases  of  rheumatism  complicated  with  endocarditis,  than 
in  rheumatic  cases  devoid  of  any  cardiac  complication.  Thus  Dr. 
Fuller  found  it  to  occur  in  only  7  of  127  cases  in  which  rheu- 
matism was  uncomplicated  with  disease  of  the  heart.  This  fact  may 
seem  to  show  that  pulmonary  inflammation  exerts  some  influence, 
although  feeble,  in  determining  the  occurrence  of  endocarditis.  It 
is,  however,  more  rational  to  conclude,  in  view  of  all  the  facts, 
that  there  does  not  exist  any  pathological  relation  between  pneu- 
monia or  pleurisy  and  endocarditis  when  they  are  associated,  but 
that  both  may  proceed  from  a  common  cause.  The  occurrence  of 
pulmonary  inflammation  in  a  proportion  of  cases  somewhat  larger 
when  rheumatism  is  complicated  with  endocarditis,  than  when  this 
complication  does  not  exist,  may  arise  from  a  greater  intensity  of 
the  blood  poisoning.  If  any  pathological  relation  exists,  it  is 
perhaps  as  rational  to  suppose  that  the  pulmonary  inflammation  is 
dependent  on  the  cardiac  affection,  as  that  the  former  is  involved 
in  the  causation  of  the  latter. 

'  Op.  cit. 


AETIFICIAL    PRODUCTION    OF    ENDOCARDITIS.  881 

Endocarditis  is  occasionally  developed  in  connection  with  the 
eruptive  and  continued  fevers,  and  with  the  naorbid  condition  con- 
sidered as  pyaemia.  Its  occurrence  in  these  connections,  is  rare. 
It  may  also  be  produced  by  injuries  of  the  chest ;  but  cases  of 
traumatic  endocarditis  must  be  extremely  infrequent. 

It  is  evident  from  the  foregoing  account  of  the  pathological  rela- 
tions of  endocarditis,  that,  exclusive  of  its  connection  with  acute 
rheumatism  and  Bright's  disease,  it  is,  practically,  not  of  much 
importance,  since  it  so  seldom  comes  under  the  observation  of  the 
medical  practitioner.  But,  as  before  remarked,  its  occurrence  as 
an  idiopathic  affection,  especially  in  early  life,  may  not  be  quite  as 
infrequent  as  is  generally  supposed.  The  occasional  instances  of 
valvular  lesions  in  children  who  have  not  had  acute  rheumatism, 
is  a  ground  for  suspecting  that  it  occurs  oftener  than  it  is  recog- 
nized. As  a  complication  of  rheumatism  and  Bright's  disease,  it 
possesses  very  great  importance,  in  view  of  the  frequency  of  its 
occurrence,  and  its  remote  evils.  Its  importance,  in  a  certain  point 
of  view,  is  greater  as  a  complication  of  rheumatism  than  of  Bright's 
disease,  for  in  the  latter  association  it  is  generally  combined  with 
pericarditis,  and  it  is  developed  under  circumstances  which  offer 
small  encouragement  to  expect  recovery.  On  the  other  hand,  in 
connection  with  rheumatism,  the  immediate  danger  is  slight,  and 
there  is  ground  for  hope  that  by  appropriate  management  remote 
evils  may  be  mitigated  if  not  prevented. 

The  experiments  of  Dr.  Richardson,  to  which  reference  has  been 
made,  are  of  interest  and  value  in  their  bearing  on  the  causation 
of  endocarditis.  After  injecting  into  the  peritoneal  cavity  of  the 
dog  a  solution  of  lactic  acid  containing  ten  per  cent,  of  the  acid 
(an  operation  almost  painless)  the  liquid  is  soon  absorbed,  and  in 
about  twelve  hours  the  symptoms  and  physical  signs  denote  the 
development  of  endocarditis.  The  morbid  appearances  observed 
in  different  stages  of  the  endocardial  inflammation  have  been  stated. 
These  appearances  are  mostly  confined  to  the  right  side  of  the  heart, 
and  are  especially  seated  in  the  tricuspid  valve  and  orifice.  Dr. 
Richardson  attributes  the  inflammation  to  the  local  action  of  the 
lactic  acid,  which  he  supposes  to  act  on  the  right  side  of  the  heart, 
because,  being  absorbed  by  the  veins,  "  it  comes  into  contact  with 
the  inner  surface  of  the  right  side  of  the  heart  first ;  in  the  pulmonic 
circuit,  it  undergoes  some  loss,  and  so  entering  the  left  cavity  is 
less  active  in  its  effects.  In  other  words,  in  so  far  as  the  heart  is 
concerned,  the  poison  is  derived  from  the  systemic  circuit,  and  is 


382  INFLAMMATORY    AFFECTIOXS    OF    THE    HEART. 

lost  in  the  pulmonic  circuit."  He  regards  his  experiments  as 
proving,  synthetically,  that  rheumatic  endocarditis  is  produced  by 
a  similar  agent.  Analysis  furnishes  corroborative  evidence  by 
showing  the  acidity  of  the  excreta  in  acute  rheumatism,  especially 
the  perspiration.  But  in  rheumatism  the  endocarditis  is  seated  in 
the  left,  not  in  the  right  cavities  of  the  heart.  To  account  for  this 
Dr.  Richardson  supposes  that  the  poison  in  rheumatic  endocarditis 
is  a  product  of  respiration,  and  is  contained  in  the  arterial  blood. 
"  Hence,  it  comes  in  contact,  first,  with  the  inner  surface  of  the  left 
side  of  the  heart ;  while,  in  tbe  systemic  circuit,  it  undergoes  loss 
or  combination,  so  that  the  blood  returning  by  the  veins  is  not 
poisoned,  and  the  right  side  of  the  heart  escapes."  That  the  inflam- 
mation is  produced  by  the  direct  contact  of  a  poisonous  agent,  when 
artificially  induced,  and  in  rheumatic  endocarditis,  Dr.  Eichardson 
considers  as  proved  by  the  limitation  of  the  inflammation  to  one  side 
of  the  heart,  for  if  a  blood-poison  were  to  produce  its  effect  through 
the  nutritive  vessels  of  the  part,  it  would  seem  that  the  two  sides 
of  the  heart  should  be  equally  affected,  inasmuch  as  both  are  sup- 
plied from  a  common  source  with  the  same  blood.  The  fact  that 
during  foetal  life,  when  the  lungs  do  not  fulfil  the  office  of  respira- 
tion, the  right  side  of  the  heart  is  liable  to  endocarditis  corroborates 
the  views  of  Dr.  Richardson. 

Endocarditis  may  give  rise  to  immediate  pathological  results 
which  are  important.  Among  these  are  emboli,  consisting  of  de- 
tached masses  of  fibrin  or  lymph,  or  both,  of  greater  or  less  size, 
which,  propelled  with  the  current  of  blood  into  the  arteries,  are  at 
length  arrested  in  their  course  in  trunks  too  small  to  permit  their 
farther  progress,  giving  rise  to  arterial  obstruction  and  diminished 
supply  of  blood  to  certain  parts.  This  subject  has  already  been 
considered  in  connection  with  valvular  lesions,  Chapter  III.,  to 
which  the  reader  is  referred. '  It  is  sufficient  to  say  that  the  pro- 
duction of  emboli  is  an  accidental  event  which  may  occur  during 
the  progress  of  endocarditis,  as  well  as  at  a  later  period  when 
lesions  of  the  valves  have  taken  place  as  a  remote  effect  of  endo- 
cardial inflammation.  Their  occurrence,  however,  is  more  frequent 
in  connection  with  valvular  lesions.  The  phenomena  which  are 
symptomatic  of  embolic  obstruction,  such  as  apoplectic  or  epilepti- 
form seizures,  paralysis,  etc.,  rarely  enter  into  the  clinical  history 
of  cases  of  endocarditis.     But  the  liability  to  their  occurrence,  and 

'  Virje  page  151. 


FORMATION    OF    COAGULA,   ETC.   IN    ENDOCARDITIS.    383 

the  explanation,  at  least  in  certain  instances,  should  be  borne  in 
mind. 

The  solid  deposits  in  cases  of  endocarditis,  viz.,  fibrin  and  lymph, 
are,  to  a  greater  or  less  extent,  disintegrated  by  the  blood-currents 
and  carried  into  the  circulation,  either  in  solution  or  suspended  in 
the  form  of  minute  particles.  According  to  the  observations  of 
Dr.  John  Taylor,*  the  comminuted  solid  deposits,  transported  to 
different  organs,  and  becoming  arrested  in  the  capillary  vessels, 
may  give  rise  to  vascular  obstruction  and  secondary  inflammation 
in  these  organs.  The  kidneys  and  spleen  are  most  likely  to  be  the 
seat  of  disease  thus  induced.  These  effects  are  primarily  mecha- 
nical ;  but  it  is  highly  probable  that  morbid  changes  in  the  blood 
itself  are  sometimes  induced  by  the  admixture  of  the  liquid  pro- 
ducts of  endocardial  inflammation.  It  can  hardly  be  otherwise,  if, 
as  is  not  improbable,  purulent  matter  is  occasionally  formed  on  ex- 
coriated or  ulcerated  surfaces  which  are  in  some  instances  observed 
after  death  in  cases  of  endocarditis.  Our  knowledge  of  these  effects, 
as  derived  from  clinical  facts,  however,  is  as  yet  too  meagre  to  war- 
rant any  important  conclusions.  The  fact  that  rheumatic  endocar- 
ditis very  rarely  ends  fatally,  and  rarely  presents  symptoms  which 
denote  purulent  infection  of  the  blood,  goes  to  show  the  benignity, 
in  most  instances,  of  the  liquid  or  soluble  products  of  endocarditis. 

The  formation  of  coagula  in  the  cavities  of  the  heart  belongs 
among  the  immediate  pathological  effects  of  endocarditis.  The 
contact  of  the  blood  .with  the  inflamed  membrane,  and  the  com- 
mingling of  the  liquid  products  of  endocardial  inflammation,  have 
been  supposed  to  induce  coagulation,  giving  rise  to  the  ante-mortem, 
clots  which  were  called  by  the  older  writers  polypi  of  the  heart. 
As  an  effect  purely  of  endocarditis,  this  must  be  extremely  rare,  in 
view  of  the  fact  already  repeatedly  stated,  viz.,  that  endocarditis  is 
fatal  in  but  a  very  small  proportion  of  cases.  It  is  probable  that 
when  this  event  does  occur  during  the  progress  of  endocarditis, 
other  conditions  are  involved  which  are  more  concerned  in  the 
occurrence  of  the  event  than  the  endocardial  inflammation,  such  as 
cardiac  enlargement,  weakness  of  the  heart  from  any  cause,  and  a 
state  of  the  blood  which  renders  it  prone  to  coagulation.  Clinical 
observation  fails  in  furnishing  evidence  of  the  formation  of  coagula 
during  the  progress  of  endocarditis  as  often  as  the  writings  of  Bouil- 
laud  and  some  others  would  lead  the  observer  to  expect;  but  that 

'  Walshe,  op.  cit.,  2d  English  edition,  p.  610. 


384         INFLAilMATORY   AFFECTIONS    OF    THE    HEART. 

a  certain  amount  of  agency  in  the  production  of  this  event  is  de- 
rived from  the  disease,  is  not  to  be  denied. 


Symptoms  of  Endocarditis. 

The  symptoms  of  endocarditis  are  less  distinctive  than  those  of 
pericarditis.  Occurring,  generally,  in  connection  with  acute  rheu- 
matism, its  symptomatic  phenomena  are  merged  in  those  of  the 
latter  affection.  Hence,  although  its  occurrence  as  a  complication 
of  rheumatism  is  so  frequent,  even  the  existence  of  such  a  disease 
has  been  known  only  within  a  few  years  past.  In  a  large  propor- 
tion of  cases  there  are  no  symptoms  which  attract  attention  to  the 
heart  as  the  seat  of  any  disease.  Examination,  however,  with  a 
view  to  determine  the  presence,  or  otherwise,  of  phenomena  which 
point  to  endocarditis,  may  elicit  symptoms  which  are  of  importance 
in  the  diagnosis.  These  symptoms  consist  of  pain  referable  to  the 
heart,  symptomatic  fever,  and  excited  action  of  the  organ,  or  palpi- 
tation. Symptoms  arising  from  obstruction  to  the  passage  of  blood 
through  the  orifices  of  the  heart  do  not  belong,  properly,  to  the 
symptomatology  of  endocarditis,  but  are  due  either  to  lesions  re- 
sulting from  endocardial  inflammation,  or  to  accidental  events, 
such  as  the  formation  of  coagula.  These  symptoms  have  been 
considered  in  preceding  chapters. 

Pain  is  very  rarely  a  prominent  symptom,  and  it  is  often  want- 
ing. When  present,  it  is  not  easy  to  refer  it  to  the  endocardium, 
except  by  taking  into  account  other  symptoms  and  the  physical 
signs.  The  pain  is  not  acute  or  lancinating,  but  dull,  obtuse,  or 
burning.  A  sense  of  uneasiness,  hardly  amounting  to  pain,  is 
sometimes  referred  to  the  prsecordia.  The  suffering  from  the  affec- 
tion of  the  joints  is  usually  so  much  greater  than  the  pain  arising 
from  rheumatic  endocarditis,  that  the  patient  will  not  be  likely  to 
speak  of  the  latter  until  interrogated  with  respect  to  it.  If  prascor- 
dial  pain  be  marked  in  cases  of  rheumatism,  there  is  reason  to 
suspect  not  alone  endocarditis,  but  pericarditis  or  pleurisy,  and 
these  affections  are  to  be  excluded  by  the  absence  of  other  symp- 
toms and  signs  before  concluding  that  the  pain  is  due  exclusively 
to  endocardial  inflammation. 

It  is  probable  that  inflammation  of  the  endocardium  alone  would 
generally  give  rise  to  more  or  less  febrile  movement.  But  in  cases 
of  rheumatic  endocarditis  it  is  dif&cult  to  say  how  much  of  the 


SYMPTOMS    AND    SIGNS    OF    ENDOCARDITIS.  385 

febrile  movement  is  symptomatic  of  the  cardiac  inflammation. 
Taken  alone,  this  symptom  is  in  no  wise  distinctive.  If  febrile 
movement  be  suddenly  developed  or  increased  when  it  is  not 
referable  to  a  fresh  attack  of  any  of  the  joints,  or  to  inflammation 
seated  elsewhere,  it  is  fair  to  attribute  it  to  the  occurrence  of  endo- 
carditis, if  other  symptoms  and  signs  indicate  the  existence  of  this 
affection.  Febrile  movement,  under  the  circumstances  just  stated, 
should  excite  suspicion  of  the  occurrence  of  endocarditis,  and  lead 
to  careful  examination  with  reference  to  other  symptoms  and  signs. 

Endocardial  inflammation  may  excite  the  muscular  action  of  the 
heart,  inducing  a  species  of  palpitation.  Of  this  the  patient  may 
be  conscious  and  make  complaint ;  and  it  is  apparent  to  the  hand 
placed  over  the  praecordia,  and  also  by  the  pulse.  The  action  of 
the  heart  may  be  irregular,  as  well  as  unduly  excited.  The  force 
of  the  pulse  is  observed  in  some  instances  not  to  correspond  with 
the  activity  of  the  heart,  as  shown  by  the  impulse  felt  in  the 
prascordia.  These  symptoms,  occurring  in  the  course  of  acute 
rheumatism,  should  lead  to  the  suspicion  of  cardiac  disease,  which 
may  prove  to  be  endocarditis.  Like  the  other  symptoms,  these 
alone  are  of  little  value  as  distinctive  of  the  disease,  but,  taken  in 
connection  with  other  symptoms  and  signs,  they  have  considerable 
significance. 

The  symptoms  which  have  been  mentioned  derive  their  import- 
ance, as  indicative  of  endocarditis,  chiefly  from  their  occurrence  in 
the  course  of  acute  rheumatism.  The  clinical  history  of  idiopathic 
endocarditis,  based  on  analyses  of  recorded  cases  of  the  disease,  is 
yet  to  be  written.  The  information  obtained  by  physical  explora- 
tion is  more  important,  and  to  this,  attention  will  now  be  directed. 


Physical  Signs  of  Endocarditis. 

Increased  extent  and  degree  of  dulness  on  percussion,  due  to 
tumefaction  of  the  heart  and  accumulation  of  blood  within  its 
cavities,  is  considered  by  Bouillaud  and  others  as  a  physical  sign 
of  endocarditis.  Assuming  that  these  conditions  are  incident  to 
the  disease,  it  may  fairly  be  doubted  whether  the  cardiac  enlarge- 
ment often,  if  ever,  much  exceeds  the  limit  of  healthy  variations ; 
and  if  the  size  of  the  heart  be  found  to  be  abnormal,  it  is  impossi- 
ble to  say  that  it  is  owing  to  an  existing  endocarditis,  unless  it 
have  been  ascertained  by  previous  examinations  that,  prior  to  the 
25 


886  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

present  attack,  there  was  no  enlargement  of  the  heart.  If,  by 
successive  explorations  from  day  to  day,  it  be  ascertained  that  the 
heart  becomes  enlarged,  as  it  were,  under  the  eyes  of  the  observer, 
and  it  be  clear  that  pericarditis  does  not  coexist,  the  increased  size 
may  be  attributed  to  endocardial  inflammation,  provided  other 
signs  and  the  symptoms  are  sufficient  for  the  diagnosis.  How  far 
the  size  of  the  heart  undergoes  alterations  during  the  progress  of 
endocarditis  I  am  unable  to  say  from  my  own  observations ;  but  it 
is  evident  that  percussion  cannot  afford  very  important  information 
with  reference  to  the  diagnosis  of  this  disease,  except  in  a  negative 
point  of  view,  i.  e.,  by  aiding  in  the  exclusion  of  other  cardiac 
affections,  more  especially  pericarditis.  In  this  point  of  view  it  is 
of  much  importance. 

Palpation  and  inspection  furnish  evidence  of  excited  action  of 
the  heart.  The  impulse  is  seen  and  felt  to  be  more  violent  than  in 
health,  or  out  of  proportion  to  the  amount  of  febrile  movement 
which  exists.  These  signs,  however,  are  present  in  but  a  certain 
proportion  of  cases,  and  may  continue  only  during  the  early  part 
of  the  disease.  Moreover,  abnormal  activity  of  the  heart,  giving 
rise  to  increased  force  and  extent  of  impulse,  is  sufficiently  common 
in  cases  of  functional  disorder,  irrespective  of  endocarditis.  The 
signs  furnished  by  these  methods  of  exploration,  are,  therefore,  of 
little  value  except  as  associated  with  other  evidence  of  endocardial 
inflammation. 

The  only  positive  proof  of  the  existence  of  endocarditis,  is  de- 
rived from  auscultation,  and  consists  mainly  in  the  presence  of  an 
endocardial  murmur.  Clinical  experience  has  established  the  fact 
that,  as  a  rule,  a  murmur  accompanies  inflammation  of  the  endo- 
cardium. This  murmur  is  usually  soft,  having  the  character  of  a 
bellows-sound,  and  is  systolic,  i.  e.,  accompanies  the  first  or  systolic 
sound  of  the  heart.  It  is  not,  however,  developed  always,  and  per- 
haps but  rarely,  at  the  commencement  of  the  inflammation.  A 
certain  period  elapses  before  this  sign  is  discovered,  and  this  period 
probably  varies  in  different  cases.  It  is  not  easy  to  determine  the 
interval  in  many  instances,  since  the  existence  of  endocarditis  is  not 
positively  determinable  prior  to  the  production  of  a  bellows-mur- 
mur. An  approximation  to  correctness  of  observation  with  respect 
to  this  point,  is  obtained  by  ascertaining  the  duration  of  the  symp- 
toms which  point  to  cardiac  disease,  anterior  to  the  development  of 
the  murmur.  The  average  duration  of  inflammation  before  mur- 
mur occurs,  is  yet  to  be  determined.     Dr.  Richardson  found  that  a 


AUSCULTATION    IN    ENDOCARDITIS.  387 

murmur  invariably  followed  the  symptoms  of  endocarditis  arti- 
ficially induced  in  inferior  animals,  the  interval  varying  in  his 
different  experiments.  We  are  not,  however,  warranted  in  stating 
that  endocarditis  never  exists  without  a  murmur  being  produced, 
sooner  or  later,  during  the  progress  of  the  disease.  The  exceptions 
to  the  rule  are  probably  quite  rare,  but  this  is  a  point  to  be  settled 
more  definitely  by  future  researches. 

It  is  needless  to  remark  that  an  endocardial  murmur  is  not,  in 
itself,  evidence  of  existing  endocarditis.  Murmur  occurs  in  con- 
nection with  valvular  lesions  which  have  taken  place  as  remote 
effects  of  inflammation,  or  as  results  of  other  causes.  It  occurs  in 
consequence  of  blood-changes,  independently  of  an  inflammatorv 
affection  or  any  organic  disease  of  the  heart.  The  inquiry  then 
arises,  what  are  the  circumstances  which,  taken  in  connection  with 
the  presence  of  a  murmur,  render  it  a  diagnostic  criterion  of  endo- 
carditis? This  inquiry,  from  its  obvious  practical  bearing,  claims 
careful  attention. 

The  development  of  a  murmur  in  the  course  of  acute  rheumatism, 
in  conjunction  with  symptoms  denoting  cardiac  inflammation,  ren- 
ders it  almost  certain  that  endocarditis  has  occurred.  If,  after  the 
lapse  of  several  days,  an  endocardial  murmur  be  detected,  which 
previous  explorations,  made  with  sufficient  care,  have  failed  to 
discover,  the  practitioner  should  conclude  that  it  is  a  sign  of  endo- 
carditis. This  conclusion  is  rendered  more  positive,  if  increased 
febrile  movement,  excited  action  of  the  heart,  or  pain  in  the  pras- 
cordia,  are  observed  to  precede  or  accompany  the  development  o^ 
the  murmur.  But  it  will  happen  not  infrequently  that  a  murmur 
is  present  when  the  patient  first  comes  under  observation.  This  is 
the  case  especially  in  hospital  practice,  patients  being  admitted 
after  rheumatism  has  continued  already  for  a  greater  or  less  period. 
It  happens  also  in  private  practice,  since  endocarditis  may  occur  at 
the  very  commencement  of  an  attack  of  rheumatism,  and  may  even 
precede  it.  The  difficulty,  in  these  instances,  is  to  determine  that 
the  murmur  has  been  recently  developed.  It  ma}^  have  existed 
prior  to  the  attack  of  rheumatism,  being  dependent  on  some  organic 
mischief,  or  on  inorganic  morbid  conditions.  There  is  strong 
ground  for  suspecting  that  the  murmur  pre-existed,  if  the  patient 
have  had  rheumatism  before.  This  difficulty  is  sometimes  insuper- 
able ;  but  with  reference  to  it,  several  points  are  to  be  considered. 
A  murmur  due  to  endocarditis  is  generally  referable  to  the  mitral 
orifice;  in  other  words,  it  is  either  limited  to,  or  heard  with  greatest 


388  INFLAMMATORY    AFFECTIONS    OF   THE    HEART. 

intensity  over,  or  near  the  point  of  tlie  apex-beat  of  the  heart.  It 
lias  been  seen  that  in  rheumatic  endocarditis,  the  inflammation  is 
seated  especially  at  the  mitral  valve,  and  clinical  observation  shows 
that,  in  most  instances,  the  murmur  emanates  from  this  situation. 
The  fact  of  the  murmur  being  mitral,  shows  that  it  is  not  inorganic, 
since  an  inorganic  murmur,  in  the  vast  majority  of  cases,  if  not  inva- 
riably, is  produced  at  the  arterial  orifices.  If,  however,  the  murmur 
in  question  be  aortic,  other  circumstances  are  to  be  taken  into 
account  in  determining  that  it  is  not  inorganic.  These  circum- 
stances have  been  considered  in  a  preceding  chapter.*  Having 
determined  that  the  murmur  is  not  inorganic,  the  question  then  is, 
whether  it  be  due  to  valvular  lesions  which  have  existed  for  a 
greater  or  less  period,  or  whether  it  denote  an  existing  endocar- 
ditis. Valvular  lesions  lead  to  enlargement  of  the  heart.  Now,  if 
the  heart  be  found  to  be  enlarged,  it  is  probable  that  the  murmur 
proceeds  from  valvular  lesions.  Endocarditis,  it  is  true,  may  occur, 
and  is  perhaps  more  likely  to  occur,  in  cases  of  rheumatism,  when 
the  heart  is  already  affected  with  organic  disease,  but,  under  these 
circumstances,  the  murmur  cannot  be  considered  as  a  sign  of  endo- 
carditis. On  the  other  hand,  if  the  heart  be  not  enlarged,  the 
chances  are  in  favor  of  the  murmur  being  due  to  endocarditis, 
especially  if  the  symptoms  render  the  existence  of  the  latter  pro 
bable.  Another  point  relates  to  the  murmur  itself,  assuming  that  it 
is  referable  to  the  mitral  orifice.  A  murmur  due  to  existing  endo- 
carditis is  soft,  usually  not  intense,  and  limited  to  a  circumscribed 
space.  Roughness  and  great  intensity  denote  valvular  lesions. 
Diffusion  of  the  murmur  over  the  left  lateral  and  posterior  surfaces 
of  the  chest,  indicates  lesions  which  permit  free  regurgitatioTi. 
Diastolic  murmurs  are  usually,  if  not  always,  due  to  valvular 
lesions;  consequently,  a  systolic  murmur  cannot  be  considered  as 
a  sign  of  endocarditis,  if  a  diastolic  murmur  be  also  present.  The 
previous  occurrence  of  rheumatism  is  to  be  taken  into  account. 
Other  things  being  equal,  the  chances  that  a  murmur  proceeds 
from  endocardial  inflammation  are  more  if  rheumatism  have  not 
occurred  previously.  Attention  to  these  points  will  enable  the 
practitioner  to  decide,  not  always  with  positiveness,  but  with  an 
approximation  toward  certainty,  whether  a  murmur  be,  or  be  not 
significant  of  endocarditis. 

A  murmur  developed  by  endocarditis  generally  contmues  not 

'  Fide  page  202. 


1 


AUSCULTATION    IN    ENDOCARDITIS.  389 

only  during  the  continuance  of  the  disease,  but  ever  afterward. 
There  are  exceptions  to  this  rule.  I  have  known,  in  several 
instances,  a  mitral  murmur  to  disappear  entirely  after  recover}'- 
from  rheumatic  endocarditis,  when,  during  the  progress  of  ,the 
disease,  and  for  some  time  afterward,  it  had  been  well  marked  and 
constant.  This  is  to  be  accounted  for  by  supposing  that  the  swell- 
ing of  the  valves  diminishes,  the  deposits  of  lymph  and  fibrin  arc 
gradually  disintegrated  and  washed  awa_y,  and  the  endocardial 
surface  is  rendered  smooth  by  the  currents  of  blood,  so  that  the 
physical  conditions  for  the  production  of  murmur  are  no  longer 
present.  But  in  the  majority  of  cases  the  murmur  not  only  per- 
sists, but  increases  rather  than  diminishes  in  intensity,  in  proportion 
as  valvular  lesions  become  more  and  more  declared.  It  may  con- 
tinue, however,  for  many  years  without  any  notable  alteration. 

What  are  the  physical  conditions  incident  to  endocarditis  which 
give  rise  to  a  murmur?  It  is  probably  due  to  roughness  of  the  endo- 
cardial membrane  covering  the  valves,  produced  by  the  deposits  of 
lymph  and  fibrin.  It  has  been  conjectured  that,  in  consequence  of 
spasmodic  action  of  the  papillary  muscles,  the  mitral  valve  fails  to 
fulfil  its  function,  and  regurgitation  takes  place.  This  is  incon- 
sistent with  the  constancy  of  the  murmur  and  its  persistence  after 
recovery  from  the  endocarditis.  It  is  not  necessary  to  assume  the 
occurrence  of  regurgitation  in  order  to  account  for  a  mitral  systolic 
murmur.  The  murmur  is  produced  in  the  ventricle,  in  other  vfords, 
it  is  intra-ventricular,  although  emanating  from  the  mitral  orifice. 
The  presence  of  the  solid  products  of  inflammation  is  sufficiently 
adequate  to  explain  the  occurrence  of  the  soft,  feeble  and  circum- 
scribed murmur  which  characterizes  endocarditis.' 

The  heart-sounds  may  present  certain  abnormal  modifications  in 
endocarditis.  Reduplications  are  sometimes  observed.  One  or 
both  of  the  sounds,  the  first  sound  more  especially,  may  be  less 
distinct  than  in  health.  The  first  sound  may  be  wanting.  Dr. 
Richardson,  in  his  experiments,  found  that  the  first  sound  frequently 
disappeared  for  some  time  before  a  murmur  was  developed.     It  is 

'  I  should  add  that  I  liave  observed  a  mitral  systolic  murmur  to  disappear  before 
the  termination  of  rheumatism.  I  have  even  noted  the  existence  of  this  murmur 
during  one  day  only,  careful  auscultation  failing  to  discover  any  the  day  previous 
and  subsequently.  But  in  this  case  it  seems  to  me  more  reasonable  to  attribute 
the  production  of  the  murmur  to  the  deposit  of  fibrin  or  lymph  which  was  soon 
washed  away  by  the  currents  of  blood,  than  to  spasmodic  action  of  the  papillary 
muscles. 


390  INFLAMMATORY    AFFECTIONS    OF    THE    nEART. 

not  difficult  to  conceive  of  this  in  view  of  the  great  swelling  of  the 
auriculo-ventricular  valves  which  he  observed  when  the  animals 
were  killed  during  the  early  stage  of  the  inflammation — the  seg- 
ments resembling  an  injected  uvula,  and  lying  so  close  to  each  other 
that,  when  the  heart  was  contracting,  they  must  have  cushioned 
against  each  other,  fulfilling  their  office  of  preventing  regurgitation 
without  tension  or  movement.  Theoretically,  it  would  be  expected 
that  the  mitral  valvular  element  of  the  first  sound  should  be  lessened 
or  extinguished,  the  tricuspid  valvular  element  remaining  unim- 
paired. It  is  not  improbable  that  this  change  may  precede  the 
development  of  a  murmur,  and  thus  be  of  value  as  an  earlier  phy- 
sical sign  than  the  latter.  AVith  respect  to  this  point  I  cannot 
speak  from  clinical  observation. 


Diagnosis  of  Endocarditis. 

The  diagnosis  of  endocarditis  rests  on  physical  evidence.  It  is 
impossible  to  determine  the  existence  of  the  disease  by  means  of 
the  symptoms  alone;  it  is  therefore  necessarily  overlooked  by  those 
who  do  not  employ  physical  exploration.  The  evidence  consists  in 
the  development  of  an  endocardial  murmur,  in  connection  with 
symptoms  which  corroborate  its  significance.  In  a  certain  propor- 
tion of  cases,  the  diagnosis  may  be  made  with  positiveness.  When 
the  development  of  a  murmur  is  a  matter  of  observation,  under 
circumstances  which  render  the  occurrence  of  the  disease  probable, 
there  is  no  room  for  doubt.  The  diagnosis  is  less  easy,  often  diffi- 
cult, and  sometimes  impossible,  in  cases  in  which  the  newness  of  a 
murmur  is  to  be  determined,  not  by  observation,  but  inferential  1}-. 
When  this  is  the  case,  the  practitioner  is  liable  to  err,  on  the  one 
hand,  in  basing  his  diagnosis  on  the  presence  of  a  murmur  which 
is  not  newly  developed,  and,  on  the  other  hand,  in  attributing  a 
newly-developed  murmur  to  other  conditions  than  an  existing  in- 
flammation. 

In  a  patient  who  presents  unequivocal  evidence  of  valvular 
lesions,  the  diagnosis  of  endocarditis  is  extremely  difficult,  and  often 
impossible.  How  is  the  practitioner  to  determine  that  murmurs, 
under  these  circumstances,  are  due  to  existing  inflammation,  and 
not  to  the  valvular  lesions?  It  is  possible,  if  a  case  have  been 
under  observation  previously,  that  certain  changes  in  the  situation 
and  character  of  the  murmur  may  be  fairly  attributable  to  super- 


DIAGNOSIS    OF    ENDOCARDITIS.  391 

induced  endocarditis,  but  this  will  happen  in  only  a  small  propor- 
tion of  instances.  I  have  met  with  cases  repeatedly  in  which 
murmurs  connected  with  old  valvular  lesions  have  been  considered 
as  evidence  of  inflammation,  and  a  course  of  treatment  pursued 
which  was  highly  prejudicial  to  the  welfare  of  the  patients.  But 
the  error,  in  these  instances,  proceeded  from  a  very  imperfect  know- 
ledge of  the  diseases  of  the  heart.  A  question  as  to  the  existence 
of  endocarditis  in  connection  with  long  standing  organic  disease, 
can  hardly  arise  except  during  an  attack  of  acute  rheumatism. 
Not  infrequently,  under  these  circumstances,  the  question  does  arise. 
A  patient  has  had  one  or  more  previous  attacks  of  rheumatism, 
which  have  led  to  organic  disease  of  the  heart.  A  fresh  attack 
occurs.  The  symptoms  and  signs  referable  to  the  heart  may  be 
due  wholly  to  the  pre-existing  organic  disease,  or  they  may,  in  part, 
proceed  from  new  physical  conditions  incident  to  an  existing  endo- 
cardial inflammation.  To  determine  positively  with  respect  to 
this  point,  is  certainly  one  of  the  most  difficult  problems  in  diag- 
nosis. The  problem,  in  fact,  cannot  be  solved  with  positiveness. 
Cases  of  organic  disease  of  heart,  therefore,  are  to  be  excluded  from 
the  category  of  those  in  which  a  diagnosis  is  generally  practicable. 
Idiopathic  endocarditis  is  certainly  one  of  the  rarest  of  diseases. 
But,  as  already  stated,  there  is  reason  to  believe  that  it  occurs, 
especially  in  children,  when  it  is  not  recognized.  It  would  perhaps 
be  discovered  in  some  instances  in  which  it  is  overlooked,  if  prac- 
titioners, in  the  first  place,  were  more  generally  qualified  to  employ 
phj'-sical  exploration,  and,  in  the  second  place,  if  it  were  more  the 
custom  to  auscultate  the  heart  even  when  the  symptoms  do  not 
point  distinctly  to  disease  of  that  organ.  Is  the  diagnosis  of  idio- 
pathic endocarditis  practicable  ?  An  endocardial  murmur  devel- 
oped under  the  observation  of  the  practitioner,  preceded  and  ac- 
companied by  pain  or  uneasiness  in  the  praecordial  region,  febrile 
movement  and  excited  action  of  the  heart,  other  affections  which 
might  give  rise  to  these  symptoms  being  excluded,  would  warrant 
a  positive  diagnosis.  It  is,  however,  hardly  to  be  expected  that 
this  combination  of  circumstances  will  often  be  presented  in  prac- 
tice. The  symptoms  will  not  be  so  well  declared,  and  at  the  first 
examination  a  murmur  may  be  found,  the  previous  duration  of 
which  is  indeterminate.  I  confess  that  I  have  no  knowledge  of 
idiopathic  endocarditis,  derived  from  the  clinical  study  of  the  dis- 
ease, and  older,  as  well  as  better  observers  have  made  the  same 
confession.    Dr.  Stokes  remarks  with  reference  to  this  subject:  "In 


392 


INFLAMMATOEY    AFFECTIONS    OF    THE    HEART. 


truth,  we  rarely  meet  with  a  case  of  simple,  idiopathic  endocarditis 
fit  to  be  considered  as  a  type  of  the  signs  and  symptoms  of  the 
disease.     Such  a  case,  at  least,  has  never  occurred  to  me.'" 

Pericarditis  is  so  frequently  associated  with  endocarditis,  that  the 
existence  of  the  former  renders  the  coexistence  of  the  latter  highly 
probable.  But  in  some  instances  of  cndo-pericarditis,  an  endocar- 
dial murmur  may  be,  for  a  time,  wanting,  being  obscured  by  the 
friction-sound,  or  the  heart  being  too  much  weakened  by  the  com- 
pression of  liquid  eff'asion  to  produce  it.  On  the  other  hand,  the 
pressure  of  liquid  effusion  and  Ijnriph  on  the  large  vessels  within 
the  pericardium  has  been  supposed  to  give  rise,  in  some  instances, 
to  murmur  at  the  arterial  orifices.  Of  course  when  pericarditis 
exists,  symptoms  referable  to  the  heart  are  of  no  value  as  respects 
the  diagnosis  of  endocarditis.  The  combination  of  inflammation  of 
the  lining  and  investing  membrane  of  the  heart  is  more  serious 
than  either  affection  singly ;  but  happily,  the  diagnosis  of  endocar- 
ditis, under  these  circumstances,  although  it  affects  the  prognosis, 
does  not  influence  materially  the  treatment. 


Prognosis  in  Cases  op  Endocarditis. 

What  is  to  be  said  under  this  head  has  been  anticipated  in  the 
foregoing  remarks.  The  prognosis,  as  regards  immediate  danger 
to  life,  and  even  the  continuance  of  symptoms  which  occasion  in- 
convenience, is  favorable.  Recovery  in  most  instances  appears  to 
be  complete.  It  is  possible  that  the  inflammation  may  become 
chronic  and  persist  for  an  indefinite  period.  This  may  be  suspected, 
if  the  patient  complain  of  uneasiness  in  the  prascordia,  and  the 
action  of  the  heart  continues  unduly  excited.  But  our  knowledge 
of  chronic  endocarditis  is  not  sufficient  to  furnish  grounds  for  dis- 
criminating between  it  and  valvular  lesions  resulting  from  changes 
which  take  place  after  inflammatory  action  has  ceased.  Hence, 
there  is  no  advantage  in  treating  of  acute  and  chronic  endocarditis 
separately.  Certain  contingent  or  accidental  events,  of  a  serious 
nature,  to  which  reference  has  been  already  made,  are  liable  to 
occur  during  the  progress  of  endocarditis.  These  are,  the  forma- 
tion of  coagula ;  the  detachment  of  masses  of  fibrin  or  lymph,  con- 
stituting emboli;  the  admixture  of  disintegrated  solid  deposits,  and 


'  Op.  cit.,  Am.  ed.,  p.  118. 


TREATMENT    OF    ENDOCARDITIS.  393 

purulent  infection  of  the  blood.  Clinical  observation,  however, 
shows  that  in  a  large  majority  of  cases  of  endocarditis,  recovery 
takes  place  without  serious  accidents ;  the  symptoms  referable  to 
the  heart,  if  any  were  present,  disappear,  leaving  the  patient  ex- 
posed to  the  evils  arising  from  valvular  lesions  which  may  become 
developed  at  a  period  more  or  less  remote. 


Treatment  of  Endocarditis. 

The  objects  of  treatment  in  pericarditis  and  endocarditis  are  not 
in  all  respects  similar.  In  pericarditis,  the  compression  of  the  heart 
by  the  accumulation  of  liquid  within  the  pericardial  sac  is  a  source 
of  distress  and  danger.  To  prevent  this  accumulation,  and  promote 
its  removal,  are  important  therapeutical  ends.  In  endocarditis,  the 
action  of  the  heart  is  free  from  all  mechanical  restraint.  In  peri- 
carditis, the  inflammation  is  more  generally  diffused,  and  a  greater 
effect  is  produced  upon  the  muscular  walls,  first  by  excitation,  and 
afterwards  by  paralysis.  In  endocarditis,  the  inflammation  is  seated 
especially  in  the  membrane  connected  with  the  valves  and  orifices, 
where  it  is  not  in  contact  with  the  muscular  walls,  and  the  latter 
are  consequently  affected  in  a  less  degree.  In  pericarditis,  the  aim 
of  the  practitioner  is  often  to  avert  impending  death.  In  endocar- 
ditis, there  is  little  fear  of  a  fatal  result.  But  although  the  two 
affections  are  so  dissimilar  in  many  respects,  the  general  principles 
of  management  are  in  a  great  measure  alike  applicable  to  both. 

The  therapeutical  indications  in  the  treatment  of  endocarditis 
relate  mainly  to  the  alterations  to  which  the  membrane  is  exposed, 
and  to  the  products  of  inflammation.  The  objects  are  to  lessen, 
as  far  as  possible,  the  local  effects  of  the  inflammation,  to  aid  in 
restoration  from  these  effects,  and  thus  protect  the  organ  from  the 
remote  consequences  arising  from  incurable  and  progressive  un- 
soundness. These  objects  embrace  measures  having  in  view  abate- 
ment of  the  intensity  of  the  inflammation,  abridging  its  duration, 
limiting  the  exudation  of  lymph  and  the  precipitation  of  fibrin,  and 
effecting  the  removal  of  solid  deposits.  The  measures  for  these 
ends  are  those  which  were  involved  in  the  treatment  of  pericarditis, 
viz.,  bloodletting  and  other  antiphlogistic  measures,  mercurializa- 
tion,  opium,  sedatives,  eliminatives,  and  counter-irritation. 

In  the  employment  of  bloodletting,  the  practitioaer  is  to  be 
guided  by  the  same  indicating  and  contra-indicating  circumstances 


394  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

as  iu  Other  inflammations.  This  remedy  is  indicated,  and  the  ex- 
tent to  which  it  is  to  be  carried  is  to  be  regulated  by  the  apparent 
intensity  of  the  inflammation,  the  state  of  the  vascular  system,  the 
constitution  of  the  patient,  and  its  immediate  effects.  It  is  contra- 
indicated  by  weakness  of  the  circulation,  feebleness  of  constitution, 
anaemia,  and  when,  upon  trial,  want  of  tolerance  of  the  remedy  is 
apparent.  The  indications  are  present  in  a  certain  proportion  of 
the  cases  of  idiopathic  and  rheumatic  pericarditis,  but  rarely,  if 
ever,  when  the  disease  is  developed  in  connection  with  Bright's 
disease.  The  remarks  with  respect  to  this  remedy  in  pericarditis 
are,  in  general,  here  applicable ;  but  the  danger  incident  to  the 
injudicious  employment  of  bloodletting  is  greater  in  pericarditis,  in 
view  of  the  tendency  of  the  latter  to  induce  weakness  and  paralysis 
of  the  heart.  Aside  from  the  effect  of  bloodletting  in  diminishing 
the  intensity  of  inflammatory  action,  it  may  be  useful  by  lessening 
the  labor  which  the  heart  has  to  perform,  and  preventing  the  accu- 
mulation of  blood  within  its  cavities.  Bloodletting-  in  endocarditis, 
as  in  other  inflammations,  is  to  be  employed  only  during  the  early 
part  of  the  disease.  It  is  not  called  for  by  the  disease  ^er  se^  but 
by  the  circumstances  attendant  on  the  disease.  General  or  local 
bloodletting  may  be  emplo3'ed,  the  latter  when  it  is  not  desired  to 
abstract  a  large  quantity  of  blood,  or  to  withdraw  it  rapidly.  In 
most  instances  the  indications  for  bloodletting  will  be  fulfilled  by 
leeching  or  cupping. 

The  measures  which,  in  conjunction  with  bloodletting,  constitute 
the  antiphlogistic  treatment,  are  purgation  and  low  diet.  Purgative 
remedies  may  be  emploj'ed  as  a  means  of  depletion  when  circum- 
stances contra-indicate  bloodletting.  The  saline  purgatives  are  best 
suited  for  this  purpose.  Depletion  is  also  effected  indirectly  by 
limiting  the  supply  of  nutriment.  These  measures,  as  well  as 
bloodletting,  are  appropriate  to  the  early  period  of  the  inflamma- 
tion. It  is,  to  say  ihe  least,  useless  to  continue  them  after  the 
inflammation  has  continued  sufficiently  long  to  produce  all  the 
immediate  local  effects  to  which  it  is  likely  to  give  rise.  After  the 
lapse  of  a  few  days  from  the  date  of  the  attack,  they  are  not  indi- 
cated more  than,  for  example,  in  the  second  or  exudation  stage  of 
pneumonia. 

Mercury  is  generally  regarded  as  a  highly  important  remedy  in 
endocarditis,  from  its  supposed  power  in  controlling  the  processes 
of  inflammation,  restraining  exudation,  diminishing  the  tendency 
to  the  deposit  of  fibrin,  and  promoting  absorption  of  the  products 


TEEATMENT    OF    ENDOCAEDITIS.  895 

of  inflammation.  Although  its  efficacy  in  these  several  ways  has 
doubtless  been  much  exaggerated,  we  are  not  authorized  to  say 
that  it  is  in  no  degree  useful ;  and  the  evils  or  inconveniences  of 
careful  mercurialization  are  trivial  in  comparison  with  even  a  small 
amount  of  usefulness.  It  is  probable  that  all  the  benefit  to  be  ob- 
tained from  this  remedial  agent  is  secured  by  pushing  it  cautiously 
to  the  extent  of  producing  slight  ptyalism.  It  should  not  be  car- 
ried beyond  this  effect,  nor  continued  after  this  effect  is  induced.  It 
is  needless  to  add  that  mercurialization  is  improper  in  this  disease 
under  the  same  circumstances  which  contra-indicate  it  in  pericarditis 
or  other  inflammations. 

The  pain  in  endocarditis  is  rarely  sufficient  to  call  for  opiates. 
But  it  is  fair  to  infer  from  the  apparent  usefulness  of  opium  in 
inflammations  affecting  analogous  structures,  that  it  is  a  useful 
remedy  in  this  disease.  It  is  also  indicated,  as  a  sedative,  when 
the  action  of  the  heart  is  unduly  excited. 

Other  sedatives,  such  as  digitalis,  antimony  in  small  doses,  or 
the  veratrum  viride,  may  sometimes  be  useful  in  reducing  the 
excited  action  of  the  heart.  They  should  not  be  carried  to  the 
extent  of  weakening  the  heart's  action,  for,  although  there  is  not  so 
much  immediate  danger  from  this  effect  as  in  pericarditis,  it  must 
be  unfavorable  by  preventing  the  completeness  of  the  ventricular 
contractions  and  favoring  the  accumulation  of  blood  in  the  cavities 
of  the  heart. 

Eliminative  remedies  are  indicated  in  endocarditis  on  precisely 
the  same  grounds  and  to  the  same  extent  as  in  pericarditis,  when 
the  disease  occurs  in  connection  with  acute  rheumatism  or  with 
Bright's  disease.  The  treatment  in  the  latter  affections  which  is 
most  effective  in  removing  from  the  blood  the  poisonous  principles 
giving  rise  to  local  inflammations  will  prove  most  effectual  in  pre- 
venting the  development  and  the  persistence  of  endocarditis.  The 
remarks  under  this  head  in  connection  with  pericarditis  are  equally 
pertinent  to  the  present  subject,  and  need  not  be  repeated.  Certain 
facts  observed  by  Dr.  Richardson  in  his  experiments  are  interesting 
with  reference  to  the  effect  of  eliminative  remedies.  In  about  twelve 
hours  after  the  injection  of  the  lactic  acid  solution  into  the  perito- 
neum, when  the  symptoms  denoting  the  commencement  of  endo- 
carditis became  developed,  if  the  animal  was  freely  purged  or  passed 
a  large  quantity  of  urine,  the  symptoms  all  subsided,  and  renewal 
of  the  injection  was  necessary  in  order  to  sustain  the  effect. 

Counter-irritants,  viz.,  sinapisms,  blisters,  pustulation  with  croton 


396  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

oil,  and  stimulating  liniments,  are  indicated  in  the  treatment  of 
endocarditis  as  in  pericarditis,  the  only  difference  between  the  two 
afiections  as  regards  the  application  of  these  remedies  consisting  in' 
the  fact  that  in  pericarditis  the  absorption  of  liquid  effusion  may 
be  promoted  by  vesication,  while  in  endocarditis  this  is  not  an 
object  of  treatment.  ^ 

Eegarding  the  treatment  of  endocarditis  from  another  point  of 
view,  viz.,  with  reference  to  the  objects  or  indications  which  are 
presented  during  the  progress  of  the  disease,  the  measures  which 
have  been  mentioned  may  be  recapitulated,  and  some  additional 
points  relating  to  the  management  noticed. 

Bearing  in  mind  the  frequent  occurrence  of  the  disease  in  the 
course  of  acute  rheumatism,  it  is  an  indication  to  endeavor  to  pre- 
vent its-  development.  Without  discussing  the  treatment  of  rheu- 
matism, it  is  sufficient  to  say  that  measures  which  eliminate  the 
materies  morhi  from  the  blood  are  those  which,  rationally  considered, 
must  prove  most  efficient  in  the  way  of  prophylaxis.  These 
remarks  are  also  applicable  to  the  prevention  of  endocarditis  in 
cases  of  Bright's  disease. 

At  the  commencement  of  endocarditis,  and  during  the  early  part 
of  the  disease,  it  is  an  object  of  treatment  to  diminish  the  intensity 
of  the  inflammation.  This  object  is  important  not  on  account  of 
any  immediate  danger  to  life,  however  intense  the  inflammation, 
but  in  order  to  limit  its  local  effects,  more  especially  as  regards  the 
products  of  exudation.  The  means  for  accomplishing  this  object 
are  essentially  those  which  are  regarded  as  useful  at  the  onset  and 
during  the  early  stage  of  inflammation  affecting  analogous  struc- 
tures. They  consist  of  local  or  general  bloodletting  in  certain 
cases,  saline  purgatives,  and  low  diet.  In  pursuing  these  measures, 
the  practitioner  is  to  be  guided,  not  by  the  mere  fact  that  endocar- 
ditis exists,  but  by  the  associated  circumstances  in  individual  cases, 
giving  due  consideration  to  those  which  may  contra-indicate  blood- 
letting and  other  modes  of  depletion.  These  measures  are  not  to 
be  employed  or  continued  when  the  inflammation  has  existed  for 
several  days,  the  immediate  local  effects  of  the  inflammatory  pro- 
cess having  then  already  taken  place,  so  far  as  these  are  dependent 
on  the  intensity  of  the  inflammation. 

Assuming  that  mercury  exerts  any  influence  to  limit  inflamma- 
tory exudation,  it  is  indicated  at  the  commencement  of  the  disease, 
and  the  special  effects  of  this  remedy  should  be  induced  as  speedily 
as  possible,  discontinuing  it  so  soon  as  these  effects  are  produced. 


TREATMENT    OF    ENDOCARDITIS.  397 

The  solid  deposits  incident  to  endocarditis  having  been  seen  to 
consist,  in  part,  of  coagulated  fibrin  derived  from  the  blood  con- 
tained within  the  cavities  of  the  heart,  and  this  effect  being  in  a 
measure  dependent  on  an  excess  of  fibrin  in  the  blood,  especially 
when  the  disease  occurs  during  the  course  of  acute  rheumatism,  it 
is  a  rational  indication  to  endeavor  to  diminish  the  quantity  of 
fibrin  (hyperinosis)  by  therapeutical  measures.  Mercury,  and  alka- 
line remedies  have  been  supposed  to  fulfil  this  indication,  but  their 
efficiency  cannot  be  considered  as  established.  Physiological  ex- 
periments which  show  the  destruction  of  fibrin  in  the  liver  and 
kidneys,  suggest  the  inquiry  whether  remedies  exciting  the  func- 
tions of  these  orgtins  may  not  be  useful  by  reducing  an  abnormal 
proportion  of  fibrin  in  the  blood.^ 

It  is  probable  that  more  or  less  of  the  solid  deposits  which  take 
place  in  endocarditis  are  removed  by  absorption.  The  deposits 
beneath  the  endocardial  membrane  can  only  be  removed  in  this 
way.  Those  occurring  on  the  free  surface  of  the  membrane,  may 
be  removed,  partly  or  entirely,  by  the  friction  of  the  blood  in 
motion.  If  it  be  possible  to  promote  absorption  of  the  products  of 
inflammation  by  remedies,  these  are  obviously  indicated,  inasmuch 
as  the  remote  evils  of  the  disease  arise,  in  a  great  measure,  from 
the  permanence  of  the  deposits.  Mercury  and  the  iodide  of  potas- 
sium are  considered  as  useful  in  fidfilling  this  indication. 

Pain  in  some  cases,  and  more  frequently  excited  action  of  the 
heart,  call  for  opium.  This  remedy,  there  is  reason  to  believe,  is 
useful  in  this,  as  in  other  inflammations,  not  merely  as  a  palliative 
of  suffering  and  a  sedative,  but  from  a  power  of  controlling,  to 
some  extent,  the  inflammatory  processes.  Other  cardiac  sedatives, 
such  as  digitalis,  antimony,  and  the  veratrum  viride,  are  indicated 
by  excited  action  of  the  heart,  but  they  are  to  be  employed  with 
circumspection,  so  as  not  to  weaken  unduly  the  muscular  power  of 
the  organ. 

It  is  an  important  object  of  treatment  to  prevent  the  persistence 
of  endocarditis  after  it  has  existed  for  several  days,  and  its  intensity 
is  diminished.  Counter-irritant  applications  are  indicated  for  this 
object.  It  is  probable  that  these  exert  more  or  less  effect  in 
hastening  the  complete  disappearance  of  the  inflammation. 

'  Vide  Essay  on  the  Rapidity  and  Extent  of  the  Physical  and  Chemical  Changes 
in  the  Interior  of  the  Body.  By  Prof.  John  C.  Dalton.  Trans.  New  York  Aca- 
demy of  Med.,  Vol.  II.  Part  III. ;  and  New  York  Monthly  Review  of  Med.  and 
Surg.  Science,  No.  for  Sept.  1859. 


398  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

The  indications  during  convalescence,  and  subsequently,  are 
essentially  the  same  as  during  and  after  recovery  from  other  in- 
flammations affecting  important  organs.  Avoidance  of  causes 
which  may  reproduce  the  affection  is  important.  The  powers  of 
the  heart  should  not  be  unduly  tasked  by  violent  exercise,  abuse 
of  stimulants,  or  excesses  of  any  kind.  It  may  be  doubted  whether 
an  amount  of  physical  activity  necessary  to  vigorous  health,  be  un- 
favorable as  regards  the  liability  to  organic  disease.  A  restricted 
diet,  habits  of  inactivity  and  other  measures  calculated  to  enfeeble 
the  system,  are  more  likely  to  hasten  than  postpone  the  develop- 
ment of  structural  lesions.  It  is  injudicious  to  lead  the  patient  to 
anticipate  the  occurrence  of  remote  evils  which  he  may  escape,  and 
against  which,  at  all  events,  he  cannot  be  forearmed  by  being  fore- 
warned. The  moral  effect  of  looking  forward  to  organic  disease  of 
heart  may  prove  unfavorable  to  a  condition  of  mind  and  body 
which  is  not  only  conducive  to  present  comfort,  but  affords,  in 
some  degree,  a  protection  against  the  danger  to  be  apprehended. 

In  concluding  these  remarks  on  the  treatment  of  endocarditis, 
two  or  three  practical  points  remain  to  be  noticed.  In  a  pretty 
large  proportion  of  cases  the  inflammation  is  not  intense ;  it  is  evi- 
dently subacute,  at  least  as  represented  by  the  symptoms.  These 
are  so  far  from  being  prominent,  that  the  disease  is  habitually  over- 
looked by  those  who  do  not  resort  to  physical  exploration,  and  its 
occurrence  was  unknown  prior  to  the  application  of  auscultation 
to  the  study  of  cardiac  affections.  In  these  cases  the  expediency 
of  very  active  therapeutical  interference  is  doubtful.  Bloodletting 
and  other  reducing  measures  are  of  questionable  propriety,  and  the 
tendency  to  eraplo}'  heroic  remedies,  or  to  push  them  too  far,  in 
view  of  remote  evils,  is  to  be  resisted.  Here,  as  in  other  forms  of 
disease,  as  much  injury  ma}^  be  done  hy  excessive  as  by  insufficient 
treatment.  Another  point  relates  to  the  period  when  the  inflam- 
mation has  ceased,  and,  consequently,  the  indications  for  treatment 
having  reference  to  inflammation  are  no  longer  present.  It  is  not 
always  easy  to  determine  when  this  period  arrives.  But  it  is  im- 
portant to  warn  the  practitioner  against  attaching  undue  import- 
ance to  the  continuance  of  an  endocardial  murmur.  This  will  be 
likel}'  to  persist,  although  the  inflammation  does  not  continue,  for 
an  indefinite  time,  and  generally  ever  afterwards.  The  persistence 
of  the  murmur  is  no  proof  of  inflammation,  and  does  not,  of  itself, 
indicate  the  need  of  therapeutical  measures.  The  symptoms  must 
be  relied  upon  in  determining  the  intensity  of  the  inflammation 


MYOCARDITIS.  399 

during  the  course  of  the  disease,  and  the  period  of  its  cessation. 
The  latter  is  declared  by  the  disappearance  of  pain  or  uneasiness 
in  the  prascordia,  absence  of  febrile  movement,  and  quietude  of  the 
heart's  action.  Finally,  the  importance  of  not  attributing  to  endo- 
carditis the  symptoms  which  may  be  associated  with  an  endocardial 
murmur  in  cases  of  organic  disease  is  to  be  enforced.  I  have  met 
repeatedly  with  instances  of  valvular  lesions  of  long  standing,  in 
which  bloodletting,  low  diet,  mercurialization,  etc.,  had  been  em- 
ployed with  a  view  to  combat  existing  inflammation.  It  is  import- 
ant to  avoid  this  error,  since,  in  a  large  proportion  of  the  cases  of 
organic  disease  of  heart,  these  therapeutical  measures  are  injurious. 


MYOCARDITIS, 


Inflammation  of  the  muscular  structure  of  the  heart  constitutes 
the  affection  called  carditis  or  myocarditis.  Treating  of  this  affec- 
tion so  far  as  it  is  of  interest  and  importance  to  the  physician,  in  a 
practical  point  of  view,  a  brief  consideration  will  suffice,  without 
any  formal  subdivision  of  the  subject. 

The  muscular  substance  of  the  heart  is  the  seat  of  inflammation 
much  less  frequently  than  the  investing  and  lining  membranes  of 
the  organ.  But,  according  to  Rokitansky,  inflammation  occurs  in 
this  situation  oftener  than  is  generally  supposed.  As  occurring 
independently  of  pericarditis  and  endocarditis,  myocarditis  is  ex- 
tremely rare.  A  few  cases  only  are  on  record.  Either  the  peri- 
cardium or  the  endocardium,  or  both  membranes,  are  implicated  in 
the  great  majority  of  the  instances  in  which  the  muscular  tissue  is 
found  after  death  to  present  the  evidences  of  inflammation.  The 
inflammation,  probably,  in  most  instances,  extends  from  the  invest- 
ing or  lining  membrane  to  the  muscular  substance;  but  the  latter 
may  be  primarily  affected.  The  inflammation  is  usually  limited  to 
certain  portions  of  the  heart,  and  it  occurs  much  oftener  in  the  left 
than  in  the  right  ventricle.  It  may  be  confined  to  the  outer  or 
inner  layers  of  muscular  fibres,  or  it  may  extend  throughout  the 
walls,  and  affect  the  columnar  carnece.  The  septum  is  less  liable  to 
be  affected  than  the  ventricular  walls. 

If  suppuration  take  place,  pus  is  found  either  in  small  collections, 
forming  abscesses,  or  infiltrated  more  or  less  throughout  the  mus- 


400  INFLAMMATORY    AFFECTIONS    OF    THE    HEART. 

cular  walls.  When  abscesses  exist,  the  surrounding  parts  present, 
at  the  same  time,  purulent  infiltration.  The  formation  of  abscesses 
involves  destruction  of  the  muscular  structure  to  a  greater  or  less 
extent.  Thej  are  usually  formed  in  the  left  ventricle.  In  a  case 
reported  by  Dr.  Graves,  a  collection  of  two  ounces  of  pus  was  found 
in  the  walls  of  this  ventricle.  The  muscular  substance  in  the  parts 
infiltrated  is  livid,  softened,  and  more  or  less  disintegrated.  Ab- 
scesses may  discharge  their  contents,  by  perforation,  into  the  peri- 
cardial sac,  giving  rise  to  acute  pericarditis,  if  the  latter  be  not 
already  present.  Or  they  may  evacuate  into  the  ventricular  cavity, 
in  this  case  giving  rise  to  purulent  infection  of  the  blood.  In  either 
case  a  fatal  result  is  inevitable.  An  abscess  formed  in  the  ventricu- 
lar septum  has  been  known  to  lead  to  communication  between  the 
two  ventricles. 

Another,  and,  according  to  Eokitansky,  a  more  frequent,  termi- 
nation of  myocarditis  is  induration  of  the  walls  of  the  heart  from 
the  deposit  of  lymph  and  the  formation  of  fibroid  tissue.  This 
termination  involves  weakness  and  atrophy  of  the  muscular  sub- 
stance. 

An  ulterior  result  of  myocarditis  is  aneurismal  dilatation  of  the 
walls  of  the  heart.  These  are  fully  described  by  Eokitansky,  and 
have  been  referred  to  in  a  previous  chapter.  Eupture  of  the  heart 
is  an  event  in  some  instances  incidental  to  inflammation  of  the 
cardiac  substance. 

Clinically  considered,  myocarditis  is  almost  invariably  associated 
with  pericarditis,  endocarditis,  or  endo-pericarditis,  and  its  existence 
is  not  determinable  during  life.  It  may  sometimes  be  suspected 
when  the  gravity  of  the  cardiac  symptoms  is  out  of  proportion  to 
the  apparent  amount  of  endocardial  or  pericardial  inflammation. 
But  this  statement  is  indefinite.  There  are  no  symptoms  nor  signs 
which  warrant  a  diagnosis  even  approximating  to  positiveness. 
This  remark  will  apply  also  to  the  very  rare  instances  in  which 
inflammation  is  limited  to  the  muscular  substance,  the  lining  and 
investing  membranes  remaining  unaffected.  There  would,  there- 
fore, be  no  advantage,  practically,  in  dwelling  on  the  subject.  It  is 
obvious  that  in  proportion  as  myocarditis  is  added  to  endocarditis 
and  pericarditis,  singly  or  conjoined,  the  symptoms  referable  to  the 
heart  will  denote  increased  gravity  of  cardiac  disease,  and  the  im- 
mediate danger  is  augmented.  The  patient  is  also  exposed  to  certain 
accidents  which  have  been  mentioned,  viz.,  rupture,  aneurismal 


MYOCARDITIS.  401 

dilatation,  perforation  of  the  inter- ventricular  septum,  and  purulent 
infection  of  the  blood.  The  discovery  of  these,  during  life,  does  not 
come  within  the  reach  of  diagnosis. 

As  regards  the  treatment  both  of  myocarditis  and  its  accidents, 
the  therapeutical  measures  which  are  likely  to  prove  of  any  avail 
are  perhaps  indicated  by  the  symptoms  as  clearly  as  if  the  diagnosis 
were  practicable. 


26 


CHAPTER    IX. 

FUNCTIONAL   DISOEDER    OF    THE    HEART. 

Definition,  and  the  different  forms  of  disorder — Pathological  relations  and  causation  of 
functional  disorder — Association  with  plethora,  anaemia,  various  derangements  of  the 
nervous  system,  dyspepsia,  gout,  etc. — Symptoms  of  functional  disorder — Physical  signs 
furnished  by  percussion,  palpation,  and  auscultation — Diagnosis  of  functional  disorder — 
Prognosis — Treatment. 

By  functional  disorder  of  the  heart  is  meant  disturbed  action 
occurring  independently  of  either  inflammatory  or  organic  affections. 
These  affections  usually  involve  more  or  less  functiontil  disorder, 
but  the  latter  often  occurs  when  the  former  are  not  present,  being 
purely  dynamic,  or  pertaining  exclusively  to  the  vital  properties 
of  the  organ.  In  most  instances  the  disturbed  action  of  the  heart 
is  evidently  due  to  morbid  conditions  seated  elsewhere.  It  is 
usually  sjmiptomatic  of  either  blood-changes,  or  affections  of  the 
nervous  system,  and,  not  infrequently,  of  both  conjoined.  These 
morbid  conditions,  although  they  are  independent  of  inflammation 
and  structural  lesions,  may,  nevertheless,  be  associated  with  the 
latter.  It  is  a  fact  important  to  be  borne  in  mind,  that  disordered 
function  of  the  heart,  in  certain  cases  of  inflammatory,  and,  more 
especially,  organic  affections,  involves  the  same  morbid  conditions 
which  often  exist  independently  of  these  affections.  This  is  a  prac- 
tical point  which  will  be  again  referred  to.  The  subject  of  func- 
tional disorder  of  the  heart  is  of  great  importance  in  a  practical 
point  of  view,  on  account  of  the  frequency  of  its  occurrence,  the 
anxiety  which  it  occasions,  and  the  liability  of  confounding  it  with 
organic  disease.  Of  the  persons  who  make  complaint  of  symptoms 
referable  to  the  heart,  a  large  majority  suffer  from  functional  dis- 
order only.  But  the  discrimination  of  functional  from  organic 
affections  can  only  be  made  by  one  who  is  thoroughly  acquainted 
with  the  subject.  The  immense  importance  of  discriminating  cor- 
rectly is  obvious,  wdien  it  is  considered  that  structural  lesions 
involve  more  or  less  danger,  while  disorder  of  function,  although 


VAEIETIES    OF    FUNCTIONAL    DISORDER.  403 

often  in  a  high  degree   distressing,  very  rarely,  if  ever,  proves 
serious. 

Functional  disorder  of  the  heart  is  not  always  identical,  but 
presents  certain  varieties  in  different  cases,  Tn  the  mildest  form  of 
disorder,  the  action  of  the  heart  is  simply  increased  unduly  by 
transient  exciting  causes,  such  as  mental  emotions,  muscular  exer- 
cise, ingestion  of  food  or  stimulants,  etc.  The  organ  is  morbidly 
excitable,  but  its  action  is  not  disturbed  to  an  extent  to  occasion 
great  inconvenience  or  annoyance. 

Persisting  inordinate  action  is  another  form  of  disorder.  I  have 
met  with  several  instances  in  which  the  heart  acted  regularly,  but 
with  abnormal  rapidity  and  force,  irrespective  of  any  excitino- 
causes,  the  excited  action  continuing  constantly  for  days,  weeks, 
and  even  months.  The  pulse  in  these  instances  was  uniformly 
frequent — from  110  to  120  per  minute.  The  patients  were  con- 
scious of  an  undue  force  of  impulse  and  intensity"  of  the  heart- 
sounds ;  it  was  difficult  for  them  to  withdraw  their  attention  from 
the  action  of  the  heart,  and  to  overcome  a  conviction  of  the  exist- 
ence of  organic  disease.^  This  is  not  a  frequent  form  of  disorder. 
It  is  observed  in  females  much  oftener  than  in  males,  and  it  is 
sometimes  associated  with  enlargement  of  the  thyroid  body  and 
protuberance  of  the  eyeballs. 

As  commonly  presented  in  practice,  functional  disorder  occurs 
in  paroxysms,  and  the  rhythm  of  the  heart's  action  is  disturbed. 
Either  with  or  without  an  obvious  exciting  cause,  the  patient  is 
conscious  of  violent  beating  of  the  heart.  The  movements  of  the 
organ,  in  severe  cases,  are  tumultuous  and  extremely  irref>-ular-  the 
systolic  contractions  at  one  instant  following  in  rapid  succession,  at 
another  instant  more  slowly,  and  intermittency  occurring  more  or 
less  frequently.  The  patient  is  painfully  conscious,  not  only  of  the 
morbid  intensity  of  the  action,  but  of  the  rhythmical  disturbance. 
Absolute  repose  is  necessary.  A  feeling  of  impending  death  is 
experienced.  Great  auxiety  and  apprehension  usually  accompany 
the  paroxysms,  especially  at  first.  The  terror  of  the  patient,  in 
fact,  not  infrequently  enhances  considerably  the  disorder.  The 
paroxysms  may  continue  for  a  few  moments  only,  or  for  several 
hours.  Their  severity  varies  much  in  different  cases.  In  mild 
cases,  as  when  they  occur  in  connection  with  hysteria,  the  sense  of 
disturbance  consists  in  fluttering  movements  referred  to  the  pra3- 
cordia.    As  regards  the  recurrence  of  the  paroxysms,  cases  vary 

'  Case  of  Mrs.  M.,  Private  Records,  vol,  ix,  p.  424. 


404  FUNCTIONAL    DISOEDEK    OF    THE    HEART. 

greatly.  They  may  recur  at  short  intervals,  being  easil}''  provoked 
by  various  exciting  causes,  and  occurring  spontaneously ;  or  they 
may  take  place  at  periods  more  or  less  remote.  The  disturbance 
of  rhythm  in  these  paroxysms  is  sometimes  so  great  that,  to  quote 
the  language  of  personification  used  by  Bouillaud,  the  heart  seems 
to  be  affected  with  a  species  of  msanif//  {une  folie  veniahle),  beating 
at  random,  instead  of  with  that  regular,  definite  purpose  which 
seems  almost  to  involve  a  motive  in  its  healthy  action. 

Another  species  of  paroxysm  is  characterized  by  irregularity 
and  intermissions,  without  increased  force  of  the  heart's  action, 
but,  on  the  contrary,  the  action  of  the  heart  may  be  quite  feeble. 
I  have  observed  these  paroxysms  to  occur  in  a  person  liable  to 
functional  disorder  of  the  heart,  especially  on  exposure  to  cold, 
during  fatigue  from  muscular  exertion,  and  when  the  habitual  time 
of  taking  food  was  delayed.  This  variety  is  even  more  distressing 
than  that  in  which  the  paroxj^sms  are  characterized  by  violence  of 
the  heart's  action.  The  feeling  of  impending  death  is  rendered 
more  vivid  by  a  tendency  to  syncope. 

Another  paroxysmal  variety  consists  in  a  sudden  momentary 
disturbance,  which  is  either  an  intermission  or  apparentl}^  a  trem- 
bling movement  of  the  heart,  occurring  at  rare  intervals,  or  more 
or  less  frequently.  These  paroxysms,  until  the  mind  becomes 
accustomed  to  them,  inspire  great  terror.  The  patient  feels,  after 
they  have  passed,  as  if  he  had  just  escaped  sudden  death,  and  this 
feeling  often  causes  the  heart  to  beat  rapidly  after  the. paroxysms 
have  ceased.  After  a  time,  patients  become  habituated  to  their 
occurrence,  and  they  occasion  much  less  apprehension.  I  have 
met  repeatedly  with  persons  who  have  been  subject  to  them  for  a 
great  number  of  years. 

These  are  the  varied  forms  under  which  functional  disorder  has 
presented  itself  in  my  own  clinical  experience.  Different  varieties, 
however,  are  frequently  associated  in  the  same  case.  All  the  forms 
are  commonly  embraced  under  the  head  of  palpitation.  They  are 
also  called,  in  distinction  from  inflammations  and  structural  lesions, 
inorganic  affections  of  the  heart.  As  before  remarked,  functional 
disorder,  in  general,  depends  on  morbid  conditions  seated  elsewhere 
than  in  the  heart.  These  causative  conditions  are  by  no  means 
the  same  in  all  cases.  A  correct  appreciation  of  the  pathological 
relations  of  the  disturbed  cardiac  action  in  individual  cases  is 
essential  with  reference  to  appropriate  treatment.  To  these  rela- 
tions attention  will  now  be  directed. 


DISORDER    IN    PLETHORA    AND    ANEMIA.  405 


Pathological  Relations  and  Causation  of  Functional  Disorder  of 

THE  Heart. 

Of  the  different  morbid  conditions  on  which  functional  disorder 
of  the  heart  is  dependent,  clinical  observation  shows  tlie  most  im- 
portant to  be  plethora,  anasmia,  derangement  of  the  nervous  system 
induced  by  various  causes,  dj'-spepsia,  and  the  gouty  diathesis. 

In  the  condition  known  as  plethora,  in  which  the  blood  is  ab- 
normally rich  in  red  globules,  and,  perhaps,  in  excess  as  regards 
quantity,  the  heart  appears  to  be  overtasked  and  over-stimulated, 
and  becomes,  in  consequence,  morbidly  irritable.  Functional  dis- 
order, thus  induced,  is  characterized  by  violence  of  action,  wdth  or 
without  disturbance  of  rhythm.  Palpitation  may  be  the  first  symp- 
tom of  the  plethoric  condition,  which  awakens  the  anxiety  of  the 
patient  respecting  the  state  of  his  health.  His  attention  is  usually 
at  once  concentrated  on  the  heart,  and  he  is  fearful  of  organic  dis- 
ease. Cases  which  fall  under  this  head  are  presented  in  persons 
who  have  altered  their  mode  of  life,  exchanging  habits  of  physical 
activity  for  sedentary  pursuits  or  luxurious  leisure.  Students 
coming  from  the  farm  or  workshop,  men  of  business  retiring  to  live 
in  ease,  and  all  who,  in  addition  to  indolence,  cultivate  the  pleasures 
of  the  table,  are  liable,  among  other  evils,  to  suffer  from  functional 
disorder  of  the  heart  incident  to  plethora.  These  cases  are  to  be 
discriminated  from  others  in  which  the  pathological  relations  are 
quite  different,  with  reference  to  the  proper  treatment. 

Cases  of  functional  disorder  are  much  oftener  met  with  in  con- 
nection with  a  condition  the  opposite  of  plethora,  viz.,  anaemia.  It 
is  rare  for  well-marked  anasmia  to  exist  without  more  or  less  dis- 
turbance of  the  heart's  action.  Cases  belonging  to  this  class  occur 
vastly  oftener  among  females  than  males,  anasmia  being  as  infre- 
quent with  the  latter,  as  it  is  common  with  the  former.  Anasmia 
being  produced  by  hemorrhages,  leucorrhcea,  frequent  childbearing, 
prolonged  lactation,  etc.,  the  functional  disorder  of  the  heart  will, 
of  course,  in  individual  cases,  be  referable  to  one  or  more  of  these 
ulterior  pathological  relations,  the  anaemia,  however,  being  the  in- 
tervening causative  condition.  But  the  degree  of  disorder  is  not 
always  proportionate  to  the  anaemia,  being  sometimes  slight  when 
the  anemic  state  is  marked,  and,  conversely,  severe  in  some  cases 
in  which  the  latter  is  scarcely  appreciable.     Anemia  giving  rise  to 


406  FUNCTIONAL    DISORDER    OF    THE    HEART, 

a  multitude  of  morbid  effects,  in  addition  to  disturbance  of  the 
heart's  action,  more  or  less  of  these  are  associated  with  the  latter. 
Patients  with  functional  disorder  dependent  on  anaemia  will  be 
likel}^  to  present  as  symptoms,  cither  coexisting  or  developed  in 
succession,  coldness  of  the  extremities,  spinal  irritation,  cephalalgia, 
neuralgic  affections  in  different  situations,  depression  of  spirits,  etc. 
Of  all  the  associated  morbid  effects  of  antemia,  the  cardiac  disorder 
often  occasions  the  most  annoj^ance  and  anxiety.  The  fear  of 
organic  disease  and  sudden  death  is  added  to  the  distress  which 
belongs  intrinsically  to  the  disorder.  In  cases  of  marked  aneemia, 
patients  are  frequently  supposed  to  labor  under  organic  disease  of 
the  heart  by  those  who  trust  exclusively  to  symptomatic  phenomena 
in  diagnosis.  The  symptoms,  in  fact,  sometimes  point  strongly  to 
the  existence  of  organic  disease.  Not  infrequently,  palpitation  is 
excited  by  the  slightest  exertion  ;  dyspnoea  is  experienced ;  pain 
or  uneasiness  is  referred  to  the  pr^ecordia;  the  countenance  is 
morbid,  and,  occasionally,  the  hydrtemic  condition  of  the  blood 
leads  to  oedema  and  anasarca.  I  have  met  with  several  instances 
in  which  all  the  symptoms  of  advanced  organic  disease  of  the  heart 
were  simulated  by  the  morbid  effects  of  anaemia  induced  by  pro- 
longed lactation  and  other  causes.  The  importance  of  a  correct 
diagnosis,  as  regards  the  prognosis  and  treatment,  in  these  cases,  is 
truly  immense. 

Derangement  of  the  nervous  system  is  doubtless  the  immediate 
cause  of  cardiac  disorder  in  cases  of  anasmia.  The  morbid  con- 
dition of  the  blood  leads  to  disturbance  of  the  heart's  action  through 
the  intervention  of  the  nervous  system.  But  the  latter  may  be 
deranged  and  functional  disorder  of  the  heart  produced  by  various 
causes,  irrespective  of  anaamia.  Cases  of  hysterical  palpitation 
come  under  this  head.  Hysteria  is  frequently,  but  by  no  means 
invariably,  associated  with  anaemia.  It  occurs  in  the  plethoric. 
Functional  disorder  of  the  heart  is  one  of  the  commonest  of  the 
varied  phenomena  included  under  the  name  of  hysteria.  Disturbed 
action  of  the  heart  is  often  a  prominent  feature  of  the  hysterical 
condition.  Various  morbid  agencies  induce  a  state  of  nervous 
derangement,  of  which  functional  disorder  of  the  heart  is  a  dis- 
tressing manifestation.  Venereal  excesses  and  the  solitary''  vice  are 
frequent  causes.  In  the  endeavor  to  trace  this  and  other  effects  of 
derangement  of  the  nervous  system  to  their  source,  the  practitioner 
should  not  omit  inquiries  as  to  sexual  indulgence  in  the  married, 
for  there  are  joersons  who  appear  to  think  that  any  amount  of 


i 


CAUSES    OF    FUNCTIONAL    DISORDEE.  407 

legitimate  indulgence  is  innocent,  and  when  questioned,  will  con- 
fess to  having  practised  one  or  more  acts  of  coition  daily  for  a 
series  of  years.  The  excessive  use  of  tobacco  is  another  cause  of 
nervous  derangement  giving  rise  to  functional  disorder  of  the  heart. 
This  is  a  frequent  cause.  Many  persons  are  led  by  their  experience 
to  observe  that  after  an  unusual  indulgence  in  this  luxury,  they  are 
apt  to  suffer  from  palpitation,  and  the  disorder  is  sometimes  re- 
moved by  simply  discontinuing  this  indulgence.  Strong  tea  in 
some  persons  occasions  severe  paroxysms  of  palpitation.  Dr. 
Stokes  has  cited  several  striking  illustrations.^  Strong  cofiee 
induces  this  effect  in  certain  conditions  of  the  system,  or  in  conse- 
quence of  a  peculiarity  of  constitution.  Excessive  mental  exercise 
and  protracted  vigilance  belong  in  this  category  ;  and,  more  than 
all,  long  continued  anxiety  or  distress  of  mind.  In  a  pretty  large 
proportion  of  the  cases  of  functional  disorder  of  the  heart,  it  is 
traceable  to  nervous  derangement  induced  by  mental  causes.  Per- 
sons are  especially  prone  to  this  disorder  who  are  so  constituted 
that,  whatever  may  be  the  circumstances  surrounding  them,  they 
are  constantly  anxious  and  worried.  In  persons  not  thus  unhappily 
constituted,  the  disorder  may  originate  in  the  severe  afflictions, 
calamities,  and  disappointments  to  which  human  life  is  exj)osed. 
AVhatever  may  be  the  causes  inducing  that  derangement  of  the 
nervous  system  which  leads  to  disturbed  action  of  the  heart,  mental 
depression  is  generally  a  prominent  symptom.  The  conviction  of 
the  existence  of  organic  disease  is  often  with  great  diflBculy  re- 
moved. The  patient  sometimes  persists  in  this  conviction  in  spite 
of  the  strongest  assurances  of  the  physician.  His  attention  is 
occupied  much  of  the  time  in  watching  the  action  of  the  heart. 
He  acquires  the  habit  of  feeling  the  pulse  or  the  beating  in  the 
prsecordial  region.  He  lives  in  daily  apprehension  of  sudden  death. 
This  truly  pitiable  condition  tends,  in  no  small  degree,  to  aggravate 
the  nervous  derangement,  and  thus  reacts  on  the  cardiac  disorder. 
Every  one  who  has  been  brought  much  into  contact  with  students 
of  medicine,  must  have  been  led  to  remark  the  frequency  with 
which  they  imagine  themselves  to  be  affected  with  disease  of  the 
heart.  The  study  of  the  diseases  of  this  organ  tends  to  direct  atten- 
tion to  the  subject  and  excite  their  fears,  if,  from  any  cause  or  com- 
bination of  causes,  functional  disorder  is  produced ;  and  the  dread 

'  Dr.  Stokes  devotes  a  section  to  "  Disturbance  of  the  heart  caused  by  the  use  of 
tea."     Vide  On  Diseases  of  the  Heart  and  Aorta,  Am.  ed.,  p.  533. 


408  FUNCTIONAL    DISORDER    OF    THE    HEART. 

of  these  diseases  seems,  in  some  instances,  to  be  alone  sufficient  to 
induce  disturbed  action  of  the  origan.  A  fixed  belief  that  the  heart 
is  diseased  is  one  of  the  commonest  of  the  delusions  incident  to 
melancholia  and  hypochondriasis. 

Disorder  of  the  heart  often  accompanies  dyspeptic  ailments.  It 
appears  to  be  produced  through  the  sympathetic  relations  existing 
between  the  heart  and  stomach.  Paroxysms  of  palpitation  are  fre- 
quently referable  to  a  fit  of  indigestion.  The  latter  may  be  the 
immediate  determining  cause  in  cases  in  which  the  disorder  involves 
other  causative  conditions  than  dyspepsia.  Dyspeptic  ailments,  in 
fact,  in  a  large  proportion  of  cases,  proceed  from  derangement  of  the 
nervous  system,  induced  especially  by  mental  distress  or  anxiety ; 
and  it  is  not  easy  to  say,  under  these  circumstances,  to  what  extent 
the  cardiac  disorder  is  dependent  on  a  morbid  condition  of  the 
stomach.  Dyspeptics  who  suffer  from  disturbed  action  of  the  heart 
are  apt  to  insist  perseveringly  on  the  existence  of  organic  disease, 
and  to  cherish  the  most  gloomy  forebodings.  They  fall  into  the 
baneful  habit  of  watching  the  action  of  the  heart  by  placing  the 
hand  over  the  prtecordia  or  on  the  pulse,  and  listening,  at  night,  to 
the  cardiac  sounds.  Under  these  circumstances  they  find  evidence 
of  disorder,  because  the  anxious  expectation  of  finding  it  is  often 
sufficient  to  produce  it. 

The  accumulation  of  gas  in  the  stomach,  when  other  dyspeptic 
symptoms  are  not  present,  seems  often  to  produce  or  increase  car- 
diac disorder.  This  may  be  owing  to  mechanical  pressure  upon 
the  heart.  Patients  suffering  nnder  paroxysms  of  palpitation  fre- 
quently make  voluntary  efforts  to  expel  wind  from  the  stomach 
by  belching,  and  express  relief  when  they  succeed  in  these  efforts. 
Carminative  remedies,  in  many  instances,  are  useful  in  this  way. 
Gastric  distension,  in  many  cases  of  hysteria,  aggravates  the  symp- 
toms referable  to  the  heart. 

The  gouty  diathesis  involves  a  liability  to  functional  disorder  of 
the  heart.  Paroxysms  are  apt  to  precede  other  manifestations  of 
this  diathesis,  occurring  before  any  affection  of  the  joints  takes 
place,  and  perhaps  ceasing  to  recur  after  the  latter  becomes  esta- 
blished. Palpitation  is  sometimes  a  premonition  of  an  approaching 
fit  of  gout.  It  may  occur  also  in  the  intervals  between  the  gouty 
affections.  The  disorder,  in  persons  subject  to  gout,  may  be  due  to 
other  morbid  conditions — for  example,  plethora  ;  but  it  is  reason- 
able to  conclude,  from  the  relations  often  observed  to  exist  between 
the  disturbed  action  of  the  heart  and  the  arthritic  attacks,  that  the 


SYMPTOMS    OF    FUNCTIONAL    DISORDER.  409 

focmer  arises  from  the  accumulation  in  the  blood  of  the  poisonous 
agent — supposed  to  be  lithic  acid — which  gives  rise  to  the  latter. 
This  view  of  the  pathology  has  an  obvious  practical  bearing  on  the 
management. 

Other  pathological  relations  of  functional  disorder  of  the  heart 
have  been  noticed  by  clinical  observers.  It  occurs  during  conva- 
lescence from  fevers.  Persons  affected  with  deformities  of  the  chest 
-seem  to  be  more  liable  to  it.  Corrigan  and  Forget  have  noticed 
its  frequent  occurrence  in  young  persons  when  growth  is  unusually 
rapid.  It  is,  apparently,  sometimes  induced  by  excessive  muscular 
exercise.  An  abnormally  small  size  of  the  heart  has  been  supposed 
to  contribute  to  its  production.  It  is  probable,  hov/ever,  that,  when 
developed  under  these  and  other  circumstances  which  might  be 
added,  the  immediate  causative  conditions  are  included  under  the 
several  classes  which  have  been  noticed,  consisting  of  abnormal 
changes  pertaining  to  the  blood,  or  derangement  of  the  nervous 
system  induced  by  various  morbid  agencies,  or  disturbing  influ- 
ences, transmitted,  by  sympathy,  from  other  organs. 


Symptoms  or  Functional  Disorder  op  the  Heart. 

The  symptomatic  phenomena  in  cases  of  functional  disorder 
differ  materially  according  to  the  various  pathological  relations  in 
which  it  is  presented  in  practice.  Associated  with  plethora,  it  is 
accompanied  by  symptoms  denoting  vascular  fulness,  such  as  a 
strong  pulse,  a  flushed  face,  cephalalgia  from  determination  of 
blood  to  the  brain,  frequently  obesity,  etc.  In  connection  with 
anasmia,  the  attendant  phenomena  indicate  feebleness  of  the  circu- 
lation ;  the  lips  are  pallid,  the  pulse  small  and  quick,  the  extremi- 
ties cold,  etc.  Dependent  on  certain  derangements  of  the  nervous 
system,  it  forms,  in  some  cases,  one  of  the  multifarious  elements  of 
hysteria;  in  other  cases,  hypochondriasis,  melancholia,  and  other 
symptoms  referable  to  this  system,  are  prominent.  As  incidental 
to  dyspepsia,  it  is  conjoined  with  notable  disorder  of  the  digestive 
functions.  Occurring  in  persons  subject  to  gout,  it  is  either  com- 
bined or  alternates  with  the  varied  ailments  incident  to  this  diathe- 
sis. These  diversified  phenomena  are  not  properly  symptoms  of 
the  cardiac  disorder,  but  pertain  to  the  different  morbid  conditions 
which  give  rise  to  it.  And,  in  fact,  as  already  stated,  functional 
disorder  of  the  heart  is  merely  a  symptom  of  these  morbid  condi- 


410  FUNCTIONAL    DISORDEE    OF    THE    HEART. 

tions,  and  not  entitled  strictly  to  be  considered  as  a  cardiac  aftection. 
There  are  certain  points,  however,  pertaining  to  symptomatology, 
which  are  of  importance  in  discriminating  functional  disorder  from 
organic  disease.  These  it  will  be  most  convenient  to  notice  in  con- 
nection with  the  subject  of  diagnosis. 


Physical  Signs  of  Functional  Disorder  or  the  Heart. 

Physical  exploration  will  be  seen  more  fully  under  the  head  of 
diao;nosis  to  be  of  immense  value  in  cases  of  functional  disorder  of 
the  heart,  as  showing  the  absence  of  the  signs  of  inflammatory  and 
organic  afi'ections.  The  information  which  it  affords  is  not  less 
positive  than  if  there  were  certain  signs  characteristic  of  functional 
disorder.  The  results  of  physical  exploration  are,  in  fact,  to  be 
considered  under  a  twofold  aspect,  viz.,  ytrs/,  as  to  the  ab.^ence  of 
abnormal  phenomena  which  denote  structural  changes;  and,  second, 
as  to  the  presence  of  the  normal  phenomena  denoting  soundness  of 
the  organ.  In  the  latter  point  of  view  the  evidence  is  positive,  in 
the  former  it  is  negative.  It  is  of  use,  practically,  to  keep  this 
distinction  in  mind.  In  exploring  the  chest,  the  practitioner  has 
always  two  objects  in  view.  One  object  is  to  ascertain  whether 
certain  well-established  signs  of  disease  are  either  present  or  want- 
ing ;  another  object  is  to  satisfy  himself  as  to  the  presence  of  the 
healthy  signs.  To  illustrate  this  distinction,  if  solidification  of  lung 
be  suspected,  auscultation  is  practised  in  order  to  discover  the  re- 
spiratory sign  of  solidification,  viz.,  the  bronchial  respiration.  Now, 
every  practical  auscultator  knows  that  the  lung  may  be  solidified, 
and  yet  this  sign  of  solidification  be  wanting.  The  evidence  against 
solidification,  therefore,  is  not  complete  when  it  is  found  that  this 
sign  is  absent.  But  let  it  be  ascertained  that,  in  ])lace  of  a  bronchial 
respiration,  the  normal  respiratory  murmur  continues,  here  is  proof 
positive  of  the  non-existence  of  solidification.  This  principle  will 
be  found  to  apply  to  the  employment  of  [physical  exploration  with 
a  view  to  determine  whether  certain  symptoms  referable  to  the 
heart  proceed  from  organic  disease  or  merely  functional  disorder. 

Of  the  several  methods  of  exploration,  percussion,  palpation,  and 
auscultation  furnish  important  information  in  cases  of  functional 
disorder. 

By  percussion  it  is  ascertained  that  the  heart  is  not  enlarged. 
Functional  disorder,  it  is  true,  may  coexist  with  cardiac  enlarge- 


1 


PHYSICAL    SIGNS    OF    FUNCTIONAL    DISORDER.  411 

meat,  the  combination  being  due  merely  to  coincidence.  It  does 
not  follow  because  the  heart  is  found  to  be  enlarged  and  other 
lesions  of  structure  are  present,  that  functional  disorder,  irrespective 
of  the  organic  disease,  does  not  exist.  But  absence  of  enlargement 
is  presumptive  evidence  that  the  disorder  is  purely  functional ;  for 
clinical  experience  teaches  that  in  cases  of  disturbed  action  of  the 
heart  arising  from  organic  disease,  the  latter  generally  has  induced 
enlargement  of  the  organ.  Percussion,  therefore,  is  of  great  utility 
in  the  discrimination  of  functional  disorder  from  affections  involv- 
ing lesions  of  structure. 

The  abnormal  force  of  the  heart's  action  is  ascertained  by  palpa- 
tion. The  impulsion  in  severe  paroxysms  of  palpitation  is  often 
violent;  the  whole  praecordia  is  agitated;  the  organ  seems  to  strike 
a  forcible  blow  against  the  thoracic  walls.  The  irregularity  of  the 
movements  of  the  organ  is  also  appreciated  by  the  hand.  These 
are  merely  signs  of  increased  and  disturbed  action  due  to  morbid 
excitement  of  the  heart.  They  do  not  indicate  the  augmented  poicer 
of  the  organ,  which  characterizes  hypertrophy.  The  impulse  in 
hypertrophy  denotes  strength  rather  than  force;  it  is  not  quick  and 
violent,  but  sluggish  and  strong;  it  does  not  give  the  sensation  of 
a  shock  or  blow,  but  it  causes  a  gradual  and  powerful  heaving  of 
the  pr£ecordia.  The  characters  obtained  by  palpation,  which  dis- 
tinguish functional  excitement  of  the  heart  from  enlargement  by 
hypertrophy,  are  sufficiently  well-marked,  and  have  been  mentioned 
already  in  treating  of  the  latter.^  The  discrimination,  however, 
does  not  rest  on  this  distinction,  for  the  fact  that  enlargement  exists, 
in  cases  of  hypertroph}^,  is  determined  by  the  coexistence  of  other 
signs.  But  it  is  to  be  borne  in  mind  that  functional  disorder  de- 
pendent on  some  of  the  morbid  conditions  which  give  rise  to  it 
independently  of  organic  disease,  may  be  associated  with  hyper- 
trophy, and,  under  these  circumstances,  the  excited  action  due  to 
the  former,  and  the  increased  power  due  to  the  latter,  are  combined. 

Palpation  shows,  in  cases  of  functional  disorder  exclusive  of 
organic  disease,  that  the  point  of  apex-beat  is  in  its  normal  situation; 
not  elevated  as  in  pericarditis  with  effusion,  nor  lowered  and  carried 
to  the  left  as  in  cases  of  enlargement  of  the  left  ventricle. 

Purring  tremor,  or  thrill,  is  said  to  be  sometimes  perceived  at  the 
base  of  the  heart  in  cases  of  purely  functional  disorder.  This  must 
be  extremely  rare.  Well-marked  thrill  is  to  be  considered  as  a 
sign  of  hypertrophy  of  the  left  ventricle  combined  with  valvular 

•   Vide  Chaj)ter  I.  p.  51. 


412  FUNCTIONAL    DISORDER    OF    THE    HEART. 

lesions.  Auscultation  furnishes  important  information, _/irs/,  nega- 
tively, by  showing  the  absence  of  adventitious  sounds  indicative  of 
valvular  lesions,  and,  second^  positively,  by  showing  that  the  natural 
sounds  preserve  their  essential  characters  and  normal  relations  to 
each  other. 

As  regards  adventitious  sounds,  the  question  arises,  may  not  an 
endocardial  murmur  be  produced  by  functional  disorder  alone  ?  It 
is  supposed  that  a  mitral  systolic  murmur  sometimes  occurs  in 
paroxysms  of  palpitation,  in  consequence  of  spasmodic  action  of  the 
papillary  muscles  connected  with  the  mitral  valve,  interfering  with 
the  action  of  the  latter  sufficiently  to  permit  a  certain  amount  of 
regurgitation  irrespective  of  any  valvular  lesions.  "Without  deny- 
ing the  possibility  of  this  occurrence,  it  must  be  extremely  rare, 
and  a  murmur  thus  produced  is  necessarily  either  intermittent  or 
of  a  transient  duration.  A  murmur  referable  to  the  mitral  orifice, 
in  the  vast  majority  of  instances,  proceeds  from  physical  changes, 
although  these  may  be  trivial  as  regards  any  immediate  effects ; 
and  if  the  murmur  be  persistent,  it  certainly  denotes  lesions,  either 
innocuous  or  otherwise.  At  the  arterial  orifices,  viz.,  the  pulmonic 
and  aortic,  a  murmur  is  often  present  in  connection  with  functional 
disorder  of  the  heart,  when  there  are  no  valvular  lesions  in  these 
situations.  This  murmur  is  therefore  inorganic,  and  in  the  great 
majority  of  cases  it  is  dependent  on  the  condition  of  the  blood. 
The  very  frequent  association  of  functional  disorder  with  anaemia, 
accounts  for  the  frequency  of  the  murmur.  May  not  the  murmur 
in  some  instances  be  dynamic,  i.  e.,  due  to  the  excited  action  of  the 
heart,  without  involving  an  abnormal  condition  of  the  blood?  The 
affirmative  is  not  improbable,  but  it  is  difficult  to  answer  this  in- 
quiry positively,  and  practically  it  is  not  very  important  to  do  so. 
The  question  to  be  settled,  clinically,  in  individual  cases  is,  whether 
a  murmur  referable  to  the  aortic  or  pulmonic  orifice,  coexisting 
with  disturbed  action  of  the  heart,  be  organic  or  inorganic.  The 
points  involved  in  the  discrimination  of  organic  and  inorganic 
murmurs  have  been  considered  in  a  preceding  chapter.'  These 
points  may  be  here  briefly  recapitulated.  An  inorganic  murmur  is 
always  systolic,  and  very  rarely,  if  ever,  rough  in  quality.  As- 
suming that  it  is  produced  at  the  arterial  orifices,  and  therefore 
seated  at  the  base  of  the  heart,  it  may  be  referred  to  the  aorta  or 
pulmonic  artery,  either  or  both ;  if  the  latter,  this  fact  renders  its 
inorganic  character  almost  certain,  provided  congenital  valvular 

>  Chapter  IV.  p.  202. 


PHYSICAL    SIGNS    OF    FUNCTIONAL    DISOKDER.  413 

lesions  are  excluded.  An  arterial  murmur  is  heard  over  the  caro- 
tids, and  perhaps  over  other  large  arteries  which  are  accessible.' 
Venous  hum  in  the  veins  of  the  neck,  especially  on  the  right  side, 
coexists  in  the  great  majority  of  instances.  The  murmur  is  usually 
feeble,  and  variable  in  intensity;  it  is  often  intermittent.  The  pal- 
pable evidences  of  anaemia  are  usually  present,  and  it  occurs  much 
oftener  in  females  than  in  males.  An  organic  murmur,  on  the 
other  hand,  may  be  diastolic,  or  systolic  and  diastolic  murmurs 
may  be  combined.  It  is  often  rough  or  musical.  It  is  referable  to 
the  aortic  orifice,  if  not  to  the  mitral,  unless  it  be  dependent  on 
congenital  valvular  lesions.  If  not  propagated  into  the  carotids, 
murmur  in  this,  as  well  as  in  other  arterial  trunks,  may  be  want- 
ing. Yenous  hum  may  not  coexist.  The  murmur  is  persistent 
and  less  fluctuating  as  regards  intensity.  Ana?mia  is  often  not 
apparent. 

Attention  to  these  differential  points  will  generally  enable  the 
practitioner  to  discriminate  correctly  between  an  organic  and  in- 
organic murmur ;  but  this  discrimination,  practically,  with  reference 
to  the  question,  whether  disturbed  action  of  the  heart  be  due  purely 
to  functional  disorder,  or  not,  is  of  less  importance  than  might  at 
first  be  supposed.  The  disturbance  is  probably  dependent  on 
functional  disorder,  whether  an  existing  murmur  be  organic  or 
inorganic,  if  the  heart  be  not  enlarged.  It  may  be  stated,  as  a  rule, 
that  valvular  lesions  do  not  give  rise  to  notable  disturbance  of  the 
heart's  action  prior  to  more  or  less  enlargement.  Hence,  cardiac 
disorder  in  a  marked  degree,  when  valvular  lesions  exist,  is  attri- 
butable to  abnormal  conditions  which  are  independent  of  the  latter. 
The  fact  already  repeated  more  than  once  is  not  to  be  lost  sight  of,, 
that  the  causes  of  functional  disorder  may  be  superadded  to  organic 
disease ;  in  other  words,  that  structural  lesions  do  not  render  the 
heart  exempt  from  the  liability  to  become  functionally  disordered] 
in  consequence  of  the  same  causes  which  occasion  disturbance  cl' 
its  action  when  it  is  structurally  sound. 

The  heart-sounds  in  cases  of  functional  disorder,  preserve  essen- 
tially their  normal  characters.  They  are,  however,  intensified  in 
proportion  to  the  increased  force  of  the  heart's  action.  Their  in- 
tensity is  often  such  that  they  are  perceived  by  the  patient  with 
great  distinctness,  especially  at  night.  The  beating  of  the  heart 
is  sometimes  distinguished  by  others  at  some  distance  from  the 

'  It  is  to  be  borne  in  mind  tliat  an  arterial  murmur  may  be  produced  simply  by- 
pressure  over  the  artery  with  the  stethoscope. 


414  FUNCTIONAL    DISORDER    OF    THE    HEART. 

chest.  The  valvular  element  of  the -first  sound  is  in  some  cases 
unusually  developed,  owing  to  the  abnormal  force  and  quickness 
of  the  systolic  contractions,  and  it  may  predominate  over  the  ele- 
ment of  impulsion,  rendering  this  sound  short  and  valvular  in 
quality  like  the  second  sound.  The  predominance  of  the  valvular 
element  of  the  first  sound  may  thus  occur  in  opposite  conditions  as 
respects  the  muscular  action  of  the  heart,  viz.,  when  it  is  enfeebled, 
and  when  it  is  excited.  The  first  sound,  more  than  the  second,  is 
affected  in  its  intensity,  by  the  vital  condition  of  the  heart.  It  is 
relatively  weakened,  and  may  be  suppressed  when  the  muscular 
power  of  the  organ  is  greatly  reduced.  On  the  other  hand,  it 
becomes  the  accentuated  sound  at  the  base,  and  at  points  removed 
from  the  priEcordial  regions,  when  the  muscular  action  is  increased 
by  morbid  excitement.  The  integrity  of  the  heart-sounds  ;  the 
normal  relative  intensity  of  the  aortic  and  pulmonic  second  sound, 
and  of  the  mitral  and  tricuspid  elements  of  the  first  sound,  constitute 
important  evidence,  in  cases  of  disturbed  action  of  the  heart,  that 
the  latter  is  due  to  simply  functional  disorder. 

The  apex-beat,  or  systolic  sound  of  the  heart,  is  sometimes  ac- 
companied by  a  ringing  intonation  called   by  Laennec  cliquement 
melallique^  or  metallic  tinnitus.    This  is  occasionally  observed  to  some 
extent,  in  health,  especially  in  young  persons,  even  when  the  heart  is 
tranquil.     It  is,  however,  in  general,  a  sign  of  excited  action  of  the 
organ.     It  may  be  imitated  by  making  light  percussion  on  the  back 
of  the  hand,  the  palmar  surface  being  applied  over  the  ear.     Hope 
explains  the  production  of  this  metallic  ringing  sound  by  supposing 
that  "the  heart  in  gliding  forwards  and  upwards  during  its  systole 
strikes  with  its  apex  against  the  inferior  margin  of  the  fifth  rib,  and 
thus  creates  an  accidental  sound,  attended  by  cliqttelis  when  the 
blow  is  smart."     He  adds:   "It  may  be  prevented  at  pleasure  by 
pressing  the  edge  of  the  stethoscope  or  anything  else  into  the  inter- 
costal space  by  which  that  space  is  put,  internally,  on  the  same 
plane  or  the  rib  over  which  the  heart  then  glides  without  catching." 
If  this  be  the  correct  explanation,  inasmuch  as  the  heart  does  not 
move  upwards  and  forwards  during  its  systole,  the  sound  must  be 
due  to  the  apex  impinging  against  the  upper  margin  of  the  sixth, 
rather  than  the  lower  margin  of  the  fifth  rib,  that  is,  assuming  the 
point  of  apex-beat  to  be  in  the  fifth  intercostal  space,  as  it  is  in  the 
majority  of  persons.     Whatever  may  be  the  explanation,  clinical 
observation  shows  that  the  sign  occurs  when  the  action  of  the  heart 
is  abnormally  o^uick  and   forcible,  and   that  it  is  produced   by  the 


DIAGNOSIS    OF    FUNCTIONAL    DISORDER.  415 

movements  of  the  apex  against  the  thoracic  walls,  can  hardly  be 
doubted.     It  may  occur  in  cases  of  hypertrophy,  but  it  is  more  apt 
to  be  developed  in  connection  with  merely  functional  disorder,  and 
it  is,  therefore,  to  some  extent,  significant  of  the  latter.      It  was 
stated  by  Hope,  that  he  never  found  it  to  occur  in  any  but  the 
meagre.     It  occurs  certainly  very  seldom  in  persons  whose  chests 
are  thickly  covered  with  muscle  or  fat.     Tympanitic  distension  of 
the  stomach  contributes  to  the  intensity  and  clearness  of  the  sound, 
and  it  may  occur  only  under  this  condition.     In  a  case  observed  by 
Dr.  Walshe  the  sound  was  so  loud  as  to  be  a  source  of  alarm  to  the 
patient.     Dr.  Stokes  remarks,  and  justly,  that  it  is  more  common 
in  cases  in  which  the  heart  acts  with  great  force  combined  with, 
regularity  of  action,  than  in  the  irregularl}''  acting  hearts.     As  a 
physical  sign,  tinnitus  is  not  of  much  practical  value,  since  it  may 
occur  when  the  heart  is  excited,  and,  under  circumstances,  when  it 
is  tranquil,  in  health,  and  since  it  occurs  in  cases  of  enlargement 
as  well  as  of  merely  functional  disorder,  although  more  frequently 
in  the  latter.     It  is  perhaps  important  to  warn  the  inexperienced 
auscultator  not  to  attach  to  it  a  degree  of  significance  as  a  morbid 
sound  to  which  it  is  not  entitled. 


Diagnosis  op  Functional  Disorder  of  the  Heart. 

The  diagnosis  of  functional  disorder  of  the  heart  involves  in  all 
cases  the  question  whether  organic  disease  be  or  be  not  present. 
The  symptomatic  phenomena  referable  to  the  heart  are  sufficiently 
explicit  as  to  their  source.  The  patient,  as  well  as  the  physician, 
is  able  at  once  to  determine  their  cardiac  origin.  But  whether 
these  phenomena  proceed  merely  from  disturbed  action,  or  are  due 
to  a  structural  affection,  is  not  so  easily  determined.  The  question 
is  one  of  great  practical  importance.  If  there  be  only  functional 
disorder,  the  physician  is  warranted  in  giving  positive  assurances 
of  the  absence  of  danger,  and  in  holding  out  confident  expectations 
of  recovery.  If  organic  disease  be  present,  such  assurances  and 
expectations  are  not  admissible.  An  intelligent  patient  is  suffi- 
ciently aware  of  the  difference  between  organic  disease  and  func- 
tional disorder  to  appreciate  its  great  importance ;  and  he  anxiously 
appeals  to  the  physician  for  positive  information  with  respect  to 
this  point.  The  ability  to  say  positively  that  organic  disease  does 
not  exist,  often  enables  the  physician  to  exert  a  moral  influence  of 


416  FUNCTIONAL    DISOEDER    OF    THE    HEART. 

no  mean  value  upon  the  continuance  of  the  malady,  as  well  as  in 
rendering  it  more  supportable.  Errors  in  diagnosis  are  quite 
common.  Instances  have  repeatedly  come  under  my  observation 
in  which  patients  suffering  only  from  disturbed  action  of  the  heart, 
having  been  told  that  they  were  afi'ected  with  organic  disease,  have 
lived  for  months  or  years  under  a  sense  of  danger  of  sudden  death, 
a  condition  of  mind  highly  conducive  to  the  perpetuation  of  the 
disorder.  On  the  other  hand,  it  is  not  uncommon  for  the  symp- 
toms connected  with  structural  lesions  to  be  imputed  to  merely 
functional  disorder.  The  latter  error,  although  less  unfortunate  as 
regards  its  consequences  than  the  former,  sometimes  leads  to  evil 
results.  If  the  physician  be  not  confident  in  his  ability  to  decide 
as  to  the  existence  or  non-existence  of  organic  disease,  but  is 
sufficiently  prudent  not  to  commit  himself  to  any  conclusion,  he 
loses  the  advantage  which  he  might  avail  himself  of,  assuming  the 
affection  to  be  merely  functional,  and  the  patient  naturally  con- 
strues his  reserve  or  indecision  into  an  unfavorable  opinion.  In 
short,  there  are  few  problems  in  clinical  medicine  more  important 
than  that  which  calls  for  a  decision  as  to  the  existence  of  a  purely 
functional  disorder  of  the  heart,  or  an  organic  affection ;  and  this 
problem  cannot  fail  to  present  itself  very  frequently  in  medical 
practice.  Cases  of  organic  disease  of  the  heart  are  not  infrequent, 
and  cases  of  merely  functional  disorder  are  exceedingly  common. 
The  importance  of  the  diagnosis  must  be  felt  almost  daily  by  the 
reflecting  and  conscientious  practitioner. 

But  the  diagnosis  involves  more  than  the  question  whether 
disease  be  or  be  not  present.  Functional  disorder  may  be  super- 
added to  organic  disease.  The  latter  may  exist,  but  not  to  an 
extent  to  occasion  immediate  inconvenience  or  danger,  the  symp- 
tomatic phenomena  being  due  to  disturbed  action  arising  from 
morbid  conditions,  independently  of  the  structural  lesions  which 
happen  to  coexist.  The  fact  that  functional  disorder  and  organic 
disease  may  be  associated,  and  the  former  not  dependent  on  the 
latter,  is  not  to  be  lost  sight  of.  Hence,  it  is  not  enough  to  decide 
that  organic  disease  is  present;  the  question  then  arises,  Is  this 
organic  disease  the  source  of  all  the  symptomatic  phenomena  refer- 
able to  the  heart,  or  are  they  not  due,  in  a  greater  or  less  degree, 
to  functional  disorder  dependent  on  morbid  conditions  which  have 
no  connection  with  the  cardiac  lesions?  This  is  a  question  of  great 
importance,  which  is  to  be  considered  in  the  cases  of  disturbed 


DIAGNOSIS    OF    FUNCTIONAL    DISOKDER.  417 

action  of  the  heart,  in  wliich  the  evidence  of  organic  disease  is 
found  to  coexist. 

The  objects  in  diagnosis,  then,  are,  first,  to  determine  whether 
organic  disease  be  or  be  not  present ;  and,  second,  if  organic  disease 
be  present,  to  determine  whether  superadded  functional  disorder  be 
not  the  source  of  more  or  less  of  the  symptomatic  phenomena 
referable  to  the  heart. 

The  symptoms  referable  to  the  heart,  separately  or  combined, 
cannot  afford  positive  evidence  in  any  case  that  cardiac  disorder  is 
purely  functional.  Yet  there  are  several  points  pertaining  to  the 
symptomatology,  exclusive  of  physical  signs,  which  are  consistent 
with  the  supposition  of  the  existence  of  functional  disorder  rather 
than  of  organic  disease.  These  points  are  to  be  considered  with 
reference  to  the  diagnosis. 

The  mental  condition  is  of  some  importance  in  a  diagnostic  point 
of  view.  Functional  disorder  generally  occasions,  in  a  marked 
degree,  anxiety  and  apprehension.  The  patient  is  often  much  agi- 
tated by  the  idea  of  an  examination,  and  awaits  the  result  with  fear 
and  trembling.  It  is  not  infrequently  difficult  to  convince  him 
that  he  has  not  an  organic  affection,  and  he  sometimes  solicits  re- 
peated examinations  lest  something  may  have  been  overlooked. 
On  the  contrary,  patients  affected  with  organic  disease  are  often,  in 
a  marked  degree,  apathetic  on  the  subject.  They  are  inclined  to 
think  that  their  ailments  proceed  from  some  other  organ  than  the 
heart,  for  example,  the  liver  or  the  stomach.  They  generally  bear 
being  told  that  the  heart  is  unsound,  without  emotion,  and  fre- 
quently with  apparent  indifference.  The  contrast  in  the  state  of 
the  mind  with  reference  to  the  question  as  to  the  existence  or  non- 
existence of  organic  disease,  is  very  striking. 

The  symptoms  due  to  disordered  action  of  the  heart  from  organic 
disease,  viz.,  palpitation,  irregularity,  intermittency,  etc.,  occasion, 
as  a  rule,  far  less  inconvenience  than  when  similar  symptoms  arise 
from  merely  functional  disorder.  It  is  surprising,  in  some  cases,  to 
what  extent  the  action  of  the  heart  is  disturbed  in  connection  with 
structural  lesions,  without  the  patient  apparently  being  conscious 
of  it.  Power  of  impulse  sufficient  to  raise  the  prascordia,  and  jar 
the  whole  body,  is  sometimes  unnoticed.  Irregular  and  intermit- 
tent action  does  not  excite  fear  of  sudden  death.  It  is  otherwise 
with  cases  of  functional  disorder.  Palpitation,  in  these  cases,  causes 
great  distress ;  and  rhythmical  disturbance  produces  fear  that  the 
action  of  the  heart  may  be  suspended,  and  a  feeling  of  impending 
27 


418  FUNCTIONAL    DISORDER    OF    THE    HEART, 

dissolution.  The  positive  suffering  from  symptoms  referable  to  the 
heart,  and  the  mental  condition,  furnish  strong  presumptive  evi- 
dence of  the  existence  of  merely  functional  disorder. 

The  paroxysmal  character  of  functional  disorder,  and  the  com- 
plete exemption,  at  certain  periods,  from  cardiac  disturbance,  are 
important  diagnostic  points.  Structural  lesions,  being  permanent, 
if  they  are  sufficient  to  occasion  much  obstruction  or  regurgitation, 
or  both,  induce,  at  length,  certain  symptoms  which  are  constant, 
such  as  feebleness,  irregularity  and  intermittency  of  the  pulse,  dys- 
pnoea on  exercise,  etc.  Functional  disorder,  on  the  other  hand, 
occurs,  generally,  in  well-marked  paroxysms,  and  after  these  have 
ceased,  the  action  of  the  heart  may  be  natural,  and  there  are  no 
symptoms  referable  to  this  organ  habitually  present.  A  patient 
who  is  able,  at  any  time,  to  take  active  exercise  without  undue  ex- 
citement of  the  heart,  or  dyspnoea,  may  be  presumed  to  be  free  from 
organic  disease.  But  it  is  not  safe  to  rely  on  the  statements  of 
patients  with  respect  to  this  point,  for  persons  affected  with  organic 
disease  are  often  unconscious  of  these  effects  of  exercise,  when  they 
are  sufficiently  apparent  to  others.  Persons  liable  to  functional 
disorder  often  are  not  only  able  to  engage,  without  discomfort,  in 
pursuits  requiring  great  muscular  exertion,  but  they  are  less  likely, 
under  these  circumstances,  to  suffer  from  cardiac  disturbance.  The 
obvious  benefit  of  active  exercise  thus  becomes,  in  some  measure, 
diagnostic.  But  the  want  of  ability  to  take  active  exercise  is  by 
no  means  proof  that  organic  disease  exists,  for  in  some  cases  of 
functional  disorder  associated  with  anseraia,  slight  exertion  may  in- 
duce palpitation,  dyspnoea,  etc. 

Certain  symptomatic  events  belong  especially  to  the  clinical 
history  of  organic  affections,  and  not  to  that  of  functional  disorder. 
Thus,  general  dropsy  very  rarely  occurs  in  connection  Avith  the 
latter.  This  is  true  of  lividity,  haemoptysis,  paralysis  from  em- 
bolia,  etc.  These  events  point  to  the  existence  of  organic  disease, 
but  their  absence  does  not  prove  that  merely  functional  disorder 
exists,  for  they  by  no  means  accompany  invariably  structural 
lesions. 

It  has  been  seen  that  functional  disorder  has  certain  pathological 
relations.  The  presence  of  the  morbid  conditions  in  connection 
with  which  it  is  apt  to  occur,  is  to  be  taken  into  account  in  the 
diagnosis.  Thus,  cardiac  disturbance  is  presumably  functional,  if  | 
it  be  connected  with  plethora,  ana?mia,  derangement  of  the  nervous 
system  from  excessive  venery,  mental  anxiety,  the  use  of  tobacco, 


Ik 


DIAGNOSIS    OF    FUNCTIONAL    DISORDER.  419 

etc.,  dyspepsia  or  gout.  On  the  other  hand,  organic  disease,  in  a 
large  proportion  of  cases,  originates  in  acute  rheumatism.  Hence, 
if  a  patient  have  never  had  the  latter  affection,  the  fact  increases 
the  chances  that  the  cardiac  disorder  is  merely  functional. 

The  age  of  the  patient  is  to  be  considered.  Functional  disorder 
occurs  especially  in  the  young,  or  between  the  age  of  puberty  and 
middle  life.  Organic  disease  is  oftener  presented  during  or  after 
the  middle  period  of  life.  Functional  disorder  is  oftener  met  with 
in  females  than  in  males ;  the  reverse  being  true  of  organic  disease. 
Organic  disease  occurs  more  frequently  among  the  laboring  classes 
of  society,  especially  those  exposed  to  the  vicissitudes  of  the 
weather;  functional  disorder  is  more  common  among  the  sedentary 
and  luxurious. 

Disturbed  action  from  functional  disorder  is  apt  to  occur  espe- 
cially at  night,  probably  because  the  mind  of  the  patient  being 
abstracted  from  outward  objects,  the  attention  is  more  likely  at 
this  time  to  be  directed  to  the  heart,  or  his  thoughts  are  more  con- 
centrated on  himself.  Persons  with  organic  disease  experience 
more  inconvenience  during  the  day-time,  when  they  are  exposed  to 
causes  which  excite  the  circulation,  such  as  exercise.  Disturbance 
of  the  heart's  action  beyond  that  which  is  habitual,  in  persons 
affected  with  organic  disease,  is  generally  proportionate  to  obvious 
exciting  causes.  On  the  other  hand,  the  action  of  the  heart  in 
cases  of  functional  disorder  is  often  out  of  proportion  to  appre- 
ciable causes;  a  sudden  start,  for  example,  sometimes  occasions 
violent  palpitation.  Severe  paroxysms  of  functional  disorder  often 
are  not  attributable  to  any  apparent  exciting  cause. 

The  foregoing  points  are  to  be  considered  in  the  discrimination  of 
functional  disorder  from  organic  disease;  but,  singly  or  colleciively, 
they  are  never  sufficiently  diagnostic  to  warrant  a  decision  that 
organic  disease  is  not  present,  A  positive  diagnosis  demands  the 
information  to  be  derived  from  physical  exploration.  The  latter 
affords  the  readiest  as  well  as  the  only  sure  way  of  coming  to  a 
decision.  The  employment  of  physical  exploration  in  ca.^es  of 
merely  functional  disorder  is  one  of  the  most  beautiful  (if  this 
expression  may  be  allowed),  as  well  as  useful,  of  the  practical  ap- 
plications of  this  method  of  examination.  A  few  moments  often 
suffice  to  decide  that  the  heart  is  free  from  structural  lesions;  and, 
reasoning  by  way  of  exclusion,  that  the  symptoms  referable  to  the 
heart  are  consequently  due  to  functional  disorder  only. 

In  excluding  organic  disease,  the  absence  of  physical  signs  refer- 


420  FUNCTIONAL    DISORDER    OF    THE    HEART. 

able  to  structural  lesions  is  to  be  ascertained.  Is  the  heart  enlarged? 
This  is  to  be  determined  by  defining  the  boundaries  of  the  super- 
ficial and  deep  cardiac  regions  by  means  which  have  been  fully 
considered  in  Chapter  I.,  and  by  ascertaining  that  the  point  of  apex- 
beat  is  within  the  range  of  healthy  variations.  Does  auscultation 
fail  in  detecting  adventitious  sounds  or  murmurs?  This  is  almost, 
if  not  quite,  enough  to  warrant  the  conclusion  that  valvular  lesions 
do  not  exist.  Are  murmurs  discovered?  Then  it  is  to  be  deter- 
mined whether  they  are  organic  or  inorganic.  The  differential 
points  involved  in  this  discrimination  have  been  mentioned  in 
another  division  of  this  chapter.  The  exclusion  of  organic  disease 
is  rendered  more  positive  by  ascertaining,  not  only  the  absence  of 
the  physical  signs  denoting  structural  lesions,  but  the  normal 
character  and  relations,  in  all  essential  particulars,  of  the  heart- 
sounds.  These  are  to  be  observed  in  different  situations,  the  aus- 
cultator  interrogating,  successively,  the  aortic,  pulmonic,  mitral,  and 
tricuspid  valves,  in  the  manner  already  described. 

But  let  it  be  assumed  that  organic  disease  is  not  excluded ;  in 
other  words,  that  the  signs  of  structural  lesions  are  present.  It  is 
to  be  determined  whether  functional  disorder  be  not  superadded. 
This  is  to  be  done  by  comparing  the  amount  of  organic  disease 
with  the  degree  of  disturbed  action.  If  the  latter  be  dispropor- 
tionate to  the  former,  it  is  probably  due,  in  a  great  measure,  to 
functional  disorder  dependent  on  other  morbid  conditions  than  the 
lesions  of  structure.  The  amount  of  organic  disease  and  the  effects 
which  are  fairly  attributable  to  them  may  be  ascertained,  approxi- 
matively,  by  means  of  the  physical  signs.  Is  the  heart  but  little, 
if  at  all,  enlarged,  and  do  the  heart-sounds  preserve  their  normal  cha- 
racters and  relations  to  an  extent  showing  that  the  lesions  cannot 
involve,  to  much  extent,  obstructive  or  regurgitant  effects;  dis- 
turbed action,  if  excessive  or  considerable,  is  probably  due  mainly 
to  superadded  functional  disorder.  It  is  important,  in  this  connec- 
tion, to  take  into  view  the  presence  or  absence  of  the  morbid  con- 
ditions which  are  likely  to  give  rise  to  functional  disorder,  viz., 
plethora,  anemia,  etc.  The  presence  of  these  conditions  adds  much 
to  the  probability  of  the  symptomatic  phenomena  referable  to  the 
heart  being  due  to  functional  disorder.  It  is  a  common  error  to 
attribute  all  these  phenomena  to  the  lesions  of  structure,  whenever 
the  existence  of  the  latter  is  determined — an  error  often  unfortu- 
nate as  regards  the  prognosis  and  treatment.  The  lesions  may  be 
innocuous,  and   the   cardiac   symptoms  dependent  altogether  on 


PROGNOSIS   IN    FUNCTIONAL    DISORDER.  421 

coexisting  functional  disorder.  It  is  to  be  borne  in  mind  that 
structural  lesions,  as  a  rule,  do  not  give  rise  to  disturbance  of  the 
heart's  action  sufficiently  to  occasion  much,  if  any,  inconvenience, 
prior  to  enlargement  of  the  organ ;  and  not  infrequently  the  organ 
becomes  considerably  enlarged  before  the  attention  of  the  patient 
is  awakened  to  any  symptoms  denoting  an  abnormal  condition  of 
the  heart. 

The  discrimination  of  cases  of  fatty  degeneration  of  the  heart 
from  those  of  purely  functional  disorder  is  sometimes  attended  with 
difficulty.  The  difficulty  arises  from  the  fact  that  this  form  of  or- 
ganic disease  does  not  present  any  positive  physical  signs.  It  is, 
therefore,  not  so  easily  excluded  as  are  valvular  afl'ections  and  un- 
complicated enlargement  of  the  heart.  In  most  instances,  however, 
enlargement  coexists  with  fatty  degeneration,  and  not  infrequently 
lesions  of  the  valves  are  also  conjoined.  Exclusive  of  these  com- 
plications, the  symptomatic  phenomena  referable  to  the  heart  in 
cases  of  fatty  degeneration  are  analogous  to  those  which  denote 
functional  disorder.  This  structural  change  occurs  at  a  period  of 
life  when  persons  are  not  so  much  exposed  to  merely  functional 
disorder  as  at  an  earlier  age.  The  palpitation  connected  with  it  has 
not  that  violence  which  frequently  characterizes  disturbed  action 
when  the  muscular  structure  is  sound.  The  paroxysmal  character 
of  merely  functional  disorder  is  less  marked.  Feebleness  of  action, 
and  perhaps  irregularity,  are  permanent  symptoms.  These  circum- 
stances, taken  in  connection  with  the  various  events  which  have 
been  noticed  under  the  head  of  the  pathological  relations  and 
effects  of  fatty  degeneration,  in  Chapter  II.,  will  generally  enable 
the  physician  to  determine  whether  this  affection  be  or  be  not 
present.  But  it  is  to  be  borne  in  mind  that  the  morbid  conditions 
giving  rise  to  functional  disorder  may  be  associated  with  fatty  de- 
generation, as  well  as  with  other  varieties  of  cardiac  lesion. 


Prognosis  in  Cases  of  Functional  Disorder  of  the  Heart. 

The  prognosis  in  cases  of  functional  disorder  of  the  heart  is  always 
favorable.  Although  the  irregularity  and  violence  of  the  disturbed 
action  are  sometimes  such  as  apparently  to  involve  immediate 
danger,  it  is  doubtful  whether  a  paroxj^sm  ever  proved  fatal ;  nor 
do  any  unpleasant  results  follow,  except  a  certain  amount  of  ex- 
haustion and   nervous   excitement.      Kecovery  from  the  morbid 


422  FUNCTIONAL    DISORDER    OF    THE    HEART. 

irritability  of  the  organ  may  be  expected,  but  it  often  tends  to  con- 
tinue for  a  considerable  length  of  time.  Of  this  the  physician 
should  be  aware,  and  it  is  well  to  forewarn  the  patient  that  the  dura- 
tion of  his  malady  may  be  tedious.  After  being  assured,  however, 
that  he  is  not  affected  with  an  organic  disease,  and  finding,  by 
experience,  that  paroxj^sms  occur  and  pass  off  without  accident  or 
injury,  he  endures  their  recurrence  with  greater  patience  than  at 
first,  and,  at  length,  if  they  are  not  severe,  he  comes  to  regard  them 
with  comparative  indifference. 

It  was  formerly  supposed  that  functional  disorder,  if  protracted, 
eventuates  in  organic  disease.  This  doctrine  has  been  disproved 
b}''  clinical  experience.  There  is  no  ground  for  the  belief  that 
changes  of  structure  ever  originate  in  disturbed  action  of  the  heart, 
however  persisting.  I  have  known  persons  who  have  suffered  from 
attacks  of  palpitation,  frequently  repeated  for  many  years,  without 
enlargement,  or  other  lesions  becoming  developed.  In  cases  in 
which  inordinate  action  has  continued  steadily  for  several  succes- 
sive months,  the  soundness  of  the  organ  has  remained  unimpaired, 
and  complete  recovery  has  taken  place.  It  is  pleasant,  as  well  as 
useful,  to  be  able  to  assure  patients  affected  with  functional  disorder 
that  they  are  not  rendered  thereby  liable  to  organic  disease. 


Treatment  of  Functional  Disorder  of  the  Heart. 

Therapeutical  indications  in  cases  of  functional  disorder  of  the 
heart,  relate  to  two  objects,  viz :  First  Relief  of  disturbed  action 
when  present.  This  object  embraces  palliative  measures  only. 
Second.  Removal  of  the  morbid  irritability  of  the  organ.  This 
object  embraces  curative  measures,  in  other  words,  those  by  which 
it  is  expected  recovery  will  be  effected. 

Curative  indications  are  derived  chiefly  from  the  pathological 
relations  and  causes  of  functional  disorder.  The  abnormal  condi- 
tions with  which  morbid  irritability  of  the  heart  is  connected, 
being  different  in  different  cases,  the  treatment  cannot,  of  course,  be 
uniform.  The  measures  of  therapeutics,  in  fact,  differ,  in  individual 
cases,  not  less  than  the  conditions  on  which  cardiac  disorder  is  de- 
pendent. 

When  associated  with  plethora,  depletory  measures  are  indicated. 
Bloodletting,  locally  or  generally,  is  judicious  in  some  cases.  It 
should,  however,  be  employed  with  circumspection.     Resorted  to 


TEEATMENT    OF    FUNCTIONAL    DISORDEE.  423 

when  not  indicated,  or  carried  too  far,  it  tends  to  aggravate  the 
cardiac  disorder.  This  is  shown  by  the  effect  of  hemorrhages,  and 
of  the  injudicious  employment  of  bloodletting,  formerly  more  than 
now,  in  various  affections.  The  "reaction  from  loss  of  blood,"  as 
illustrated  by  the  researches  of  Marshall  Hall,  and  others,  expresses 
phenomena  which  are  mainly  due  to  abnormal  irritability  of  the 
heart.  The  existence  of  plethora  is  to  be  clearly  ascertained  before 
resorting  to  bloodletting,  and  it  is  to  be  borne  in  mind  that  the 
cases  in  which  this  condition  of  the  blood  exists,  are  comparatively 
few  in  number.  In  most  instances,  if  the  existence  of  plethora  be 
sufficiently  evident,  an  adequate  amount  of  depletion  may  be  re- 
ceived by  saline  laxatives  and  a  reduced  diet.  The  latter  methods  of 
depletion  must  not  be  pushed  too  far,  or  continued  too  long.  The 
limit  is  the  restoration  of  a  normal  condition  of  the  blood.  If  the 
proportion  of  red  globules  be  reduced  below  that  of  health,  there 
is  risk  of  the  cardiac  disorder  being  increased  rather  than  diminished. 
When  the  proper  limit  is  reached,  habits  of  active  exercise  are  to 
be  conjoined  with  a  nutritious,  but  not  over-generous  diet.  Animal 
food  should  be  taken  sparingly,  and  alcoholic  stimulants  avoided. 
These  are  the  measures  indicated  by  the  coexistence  of  plethora. 

Associated  with  anaemia,  which  is  vastly  more  frequent,  the 
measures  indicated  are  the  reverse  of  those  appropriate  when 
plethora  exists.  The  treatment  now  should  be  directed  with  a 
view  to  increase  the  proportionate  quantity  of  the  red  globules  of 
the  blood.  For  this  end,  tonic  remedies,  and  especially  prepara- 
tions of  iron,  are  to  be  employed.  The  diet  should  be  highly 
nutritious,  and  consist  of  a  good  proportion  of  animal  food.  Alco- 
holic stimulants,  in  the  form  of  spirits,  wine,  beer,  or  porter,  are 
generally  useful.  Moderate  exercise  in  the  open  air  is  to  be  en- 
joined. The  causes  which  have  induced,  and  which  may  perpetu- 
ate the  anaemic  condition,  are  to  be  ascertained,  and,  if  possible, 
removed.  This  will  embrace  the  appropriate  treatment  of  various 
local  affections  which  in  females  are  often  seated  in  the  genito- 
urinary system,  such  as  leucorrhoea,  menorrhagia,  etc. ;  weaning  in 
certain  cases,  avoidance  of  pregnancy,  and,  in  short,  proper  atten- 
tion to  all  the  various  circumstances  which,  in  different  cases,  may 
be  involved  in  the  production  and  continuance  of  the  anoemiia. 
Bloodletting  and  other  measures  of  depletion,  in  cases  belonging 
to  this  class,  are  positively  pernicious,  and  may  prove  so  in  a 
marked  degree.  The  discrimination  of  these  cases  from  those  in 
which  the  cardiac  disorder  is  connected  with  plethora,  is  highly 


42-i  FUNCTIONAL    DISORDER    OF    THE    HEART. 

important  with  reference  to  appropriate  treatment.  The  fact  that, 
in  the  great  majority  of  instances,  functional  disorder  of  the  heart 
is  more  or  less  dependent  on  anaimia,  is  not  to  be  lost  sight  of. 

Derangements  of  the  nervous  system  arising  from  different  causes, 
can  only  be  treated  successfully  when  the  latter  are  ascertained  and 
removed.  Until  these  ends  are  attained,  the  cardiac  disorder  will 
be  likely  to  continue.  The  general  indication,  in  the  cases  coming 
under  this  head,  is  to  place  the  patient  without  the  influence  of 
certain  morbid  agencies.  The  most  prominent  of  these  are,  sexual 
excesses,  the  abuse  of  tobacco,  tea,  or  coffee,  excessive  mental  exer- 
tion, vigilance,  and  mental  anxiety  from  a  variety  of  causes,  real  or 
imaginary.  Curative  measures  consist  in  removing  these  causes,  so 
far  as  they  are  controllable,  together  with  the  employment  of 
remedies,  and  a  regimen  calculated  to  restore  the  healthy  condition 
of  the  nervous  system.  Change  of  scene,  the  excitement  of  travel, 
and  recreation,  are  often  highly  useful,  and  may  be  sufficient  to 
effect  recovery,  when  the  disorder  depends  mainly  on  causes  per- 
taining to  the  mind,  as  is  not  unusual.  The  importance  of  inquiry 
with  respect  to  sexual  excesses,  is  to  be  borne  in  mind.  I  have 
met  repeatedly  with  cases  in  which  cardiac  disorder  was  traceable 
to  this  source.  As  already  remarked,  it  appears  to  be  an  impression 
with  some  persons  that  indulgence  cannot  be  excessive  except 
when  it  is  meretricious ;  hence,  it  is  not  enough  to  know  that  a 
patient  is  married.  Under  the  head  of  sexual  excesses,  self-pollu- 
tion is  included.  Of  the  diflEiculty  often  in  obtaining  information 
concerning  this  matter,  especially  with  regard  to  females,  it  is  un- 
necessary to  speak.  This  may  account  for  the  obstinacy  with 
which  functional  disorder  of  the  heart  persists  in  certain  cases. 

The  coexistence  of  dyspeptic  ailments  calls  for  a  proper  regulation 
of  diet  and  regimen,  together  with  remedies  to  relieve  gastric  de- 
rangements and  improve  digestion.  So  far  as  the  cardiac  disorder 
depends  on  functional  disturbance  of  the  stomach,  the  treatment 
resolves  itself  into  that  due  to  the  latter,  of  which  the  former  is  but 
a  symptom.  To  consider  the  treatment  of  dyspepsia,  would  be 
here  out  of  place.  It  may,  however,  be  remarked  that  the  ailments 
comprehended  by  this  term  generally  involve  morbid  conditions 
seated  elsewhere  than  in  the  affected  organ,  and  often  depend  on 
mental  causes.  The  treatment,  therefore,  must  have  reference  to 
these  ulterior  conditions.  In  the  dietetic  management,  it  may  be 
added,  the  object  is  not  to  reduce  the  diet  to  an  extent  corres- 
ponding to  the  weakened  digestive  power,  but  to  invigorate  and 


TREATMENT    OF    FUNCTIONAL    DISORDEE.  425 

strengthen  the  latter,  so  that  ordinary  wholesome  articles  of  food 
may  be  taken  without  inconvenience.  The  measures  for  this  end 
are,  tonics,  stimulants,  exercise  in  the  open  air,  mental  recreation, 
and  persistency  in  a  nutritious  and  varied  diet,  in  spite  of  occasional 
symptoms  denoting  difficult  or  imperfect  digestion.  It  is  mistaken 
policy  to  watch  the  effects  of  taking  particular  articles  of  food,  and 
eliminate,  successively,  from  the  diet,  those  which  are  found  to  oc- 
casion inconvenience.  Various  accidental  causes  may  disturb 
digestion,  and  a  meal  which  on  one  day  may  be  followed  by  distress, 
on  the  next  day  may  be  taken  without  trouble.  The  practical  rule 
for  the  dyspeptic,  as  regards  diet,  is  to  eat  the  ordinary,  wholesome, 
well-cooked  varieties  of  food  in  sufficient  quantity  to  meet  the 
wants  of  the  system,  trusting  to  remedies  and  regimen  to  render  the 
digestive  organs  adequate  to  the  performance  of  their  duty.  These 
remarks  are,  of  course,  only  applicable  to  cases  of  merely  func- 
tional disturbance  of  the  stomach. 

Functional  disorder  of  the  heart  occurring  in  persons  affected  or 
threatened  with  gout,  claims  the  remedies  which  are  indicated  by 
the  gouty  diathesis.  These  are  medicines  supposed  to  act  by  elimi- 
nation, of  which  the  most  efficient  is  colchicum,  and  alkalies  given 
with  a  view  to  neutralize  the  excess  of  lithic  acid  in  the  blood. 
Of  the  latter,  potash  is  considered  as  preferable  to  soda,  in  conse- 
quence of  the  solubility  of  the  salt  formed  by  the  union  of  lithic 
acid  with  the  former.  Alkaline  remedies  and  colchicum  may  be 
combined.  The  iodide  of  potassium  has  been  found  useful.  The 
mineral  saline  waters  are  especially  suited  to  this  class  of  cases. 

The  several  morbid  conditions  which  give  rise  to  functional  dis- 
order of  the  heart,  may  be  more  or  less  combined  in  certain  cases. 
Under  these  circumstances,  the  treatment  must  have  reference,  of 
course,  to  the  different  conditions  existing  in  combination.  The 
gouty  diathesis,  for  example,  may  be  conjoined  with  plethora,  or 
dyspepsia ;  dyspepsia  and  anasmia  are  often  united,  etc.  It  is  not 
enough  to  have  ascertained  the  existence  of  one  of  the  conditions 
upon  which  cardiac  disorder  may  be  dependent;  the  inquiry  is  to 
be  extended  so  as  to  embrace  others  which  may  coexist. 

One  of  the  most  important  of  the  means  of  promoting  recovery, 
is  applicable  to  cases  occurring  in  each  and  all  of  the  different 
pathological  connections.  This  is  the  moral  influence  of  a  positive 
assurance  that  the  heart  is  free  from  organic  disease.  The  anxiety 
and  apprehension  incident  generally  to  disturbance  of  the  heart's 
action,  tend  powerfully  to  perpetuate  and  aggravate  the  disorder. 


426  FUNCTIONAL    DISORDER    OF    THE    HEART. 

If  the  physician  be  sufficiently  confident  in  his  diagnostic  ability  to 
assure  the  patient  confidently  that  the  affection  is  purely  functional 
or  inorganic,  and  the  patient  have  sufficient  confidence  in  the  know- 
ledge and  judgment  of  the  physician  to  believe  the  assurance,  this 
will  often  go  very  far  toward  promoting  a  cure.  The  effect,  in 
many  instances,  is  truly  remarkable.  Hence,  a  great  practical 
advantage  is  to  be  derived  from  a  sure  diagnosis.  An  opposite 
effect  is  equally  marked  when  the  patient  is  told  that  he  has  organic 
disease.  I  have  met  with  instances  in  which  several  years  were 
embittered  by  a  false  diagnosis  and  its  imprudent  communication. 
This,  with  the  measures  generally  advised  in  conjunction,  suffices 
to  perpetuate  the  disorder  indefinitely.  If  the  physician  be  com- 
petent to  employ  physical  exploration,  and  to  satisfy  himself  there- 
by that  organic  disease  does  not  exist,  he  should  take  pains  to 
remove  the  groundless  fears  of  the  patient,  at  the  same  time  fore- 
warning him  that  the  disorder  is  liable,  when  it  once  occurs,  to 
continue  for  a  greater  or  less  period.  If  the  patient  can  be  made 
to  believe  that  there  is  no  danger,  the  malady  is  rendered  support- 
able until  recovery  is  effected.  This  is  a  point  in  the  treatment 
of  functional  disorder  of  the  heart,  second  to  none  other.  In  all 
cases  the  patient  should  be  advised  not  to  watch  the  action  of  the 
heart  by  feeling  the  pulse  or  the  apex-beats,  or  listening  to  the 
sounds  at  night.  His  attention  should  be  diverted  from  the  dis- 
ordered organ  as  much  as  possible.  The  benefit  of  agreeable 
occupation  is,  in  part  explicable  by  its  effect  in  this  way. 

Functional  disorder,  not  dependent  on,  but  coexisting  with  or- 
ganic disease,  claims  essentially,  the  same  measures  as  when  dis- 
connected from  the  latter.  With  reference  to  treatment,  it  is 
highly  important  to  determine  that  functional  disorder  from  some 
one  or  more  of  the  morbid  conditions  which  give  rise  to  it,  is 
superadded  to  organic  disease.  I  have  met  with  instances  re- 
peatedly in  which,  in  consequence  of  this  combination,  patients 
appeared,  at  first  view,  to  be  in  an  advanced  stage  of  organic  disease, 
but  who  recovered,  by  judicious  management,  apparently,  perfect 
health.  The  practitioner  cannot  be  too  often  cautioned  not  to  attri- 
bute all  the  symptomatic  phenomena  referable  to  the  heart  to 
structural  lesions,  when  the  latter  are  found  to  exist.  The  practi- 
cal rule  may  be  here  repeated,  to  regard  these  phenomena  as  pro- 
bably due  to  functional  disorder  whenever  the  heart  is  but  little,  if 
at  all,  enlarged.  The  association  of  anrcmia  with  a  certain  amouat 
of  organic  disease  is  quite  common,  when  if  the  blood  be  restored 


TEEATMENT    OF    FUNCTIONAL    DISORDER.  427 

to  its  normal  condition,  the  cardiac  lesions  are  found  to  be,  for  a 
time  at  least,  innocuous.  But  if  the  lesions  involve  more  or  less 
obstruction  or  regurgitation,  and  enlargement  of  the  heart  have 
already  taken  place,  marked  improvement,  as  regards  the  cardiac 
and  other  symptoms,  may  be  expected  to  follow  the  removal  of  the 
conditions  which  give  rise  to  the  associated  functional  disorder. 

The  foregoing  remarks  have  had  reference  to  measures  which 
are  distinguished  as  curative.  Palliative  measures  are  now  to  be 
considered.  These  are  to  be  adapted  to  different  circumstances 
pertaining  to  the  disturbed  acti(;n  of  the  heart.  To  tranquillize  the 
excited  organ  and  restore  regularity  of  action,  are  the  ends  for 
which  palliative  measures  are  pursued.  But  the  heart  is  subject, 
as  has  been  seen,  to  various  forms  of  disorder,  and  the  condition  of 
the  organ,  as  manifested  by  the  symptoms,  is  not  precisely  the 
same  in  all  the  several  varieties.  In  the  mildest  form  of  disorder, 
in  which  only  an  occasional,  momentary  disturbance  is  felt,  there 
is  neither  necessity  nor  time  for  palliation.  Curative  measures  are 
alone  required.  Persisting,  inordinate  action,  continuing  perhaps 
for  weeks  or  even  months,  calls  for  remedies  calculated  to  allay 
this  state  of  excitement.  The  special  cardiac  sedative,  as  it  has 
been  called,  digitalis,  is  often  useful  for  this  purpose.  Hydrocyanic 
acid,  or  the  laurel  water,  hyoscyamus,  belladonna,  and  other  nar- 
cotic sedatives,  may  be  employed  in  succession.  A  belladonna 
plaster  Avorn  over  the  precordial  region  appears  frequently  to  exert 
a  happy  effect.  Opium  is  admissible,  in  some  cases,  bearing  in 
mind  the  risk  of  becoming  accustomed  to  its  use,  and  the  formation 
of  a  habit  which  is  with  difficulty  broken,  and  which  entails  evils 
of  no  small  magnitude.  Palliative  means  in  these,  as  in  other  cases, 
are,  of  course,  to  be  conjoined  with  measures  which  are  designed 
to  be  curative. 

Paroxysms  of  palpitation  characterized  by  violence  and  irregu- 
larity of  the  heart's  action,  may  be  shortened  and  mitigated  by 
palliative  measures. 

Cases  of  functional  disorder  often  come  under  the  observation  of 
the  ph^^sician,  for  the  first  time,  under  these  circumstances.  He  is 
frequently  summoned  in  haste,  and  finds,  perhaps,  the  patient  and 
friends  in  a  state  of  great  alarm.  The  first  point  is  to  give  assur- 
ance of  absence  of  danger,  so  soon  as  it  is  ascertained  that  the  dis- 
turbance is  merely  functional,  A  full  opiate  affords  often  the 
quickest  and  most  reliable  method  of  procuring  relief.  Eevulsive 
applications  are  serviceable,  such  as  sinapisms  to  the  chest,  or. 


428  FUNCTIONAL    DISORDER    OF    THE    HEART. 

compresses  moistened  with  strong  aqua  ammonite.  These  may  be 
applied  over  the  spine  if  there  be  tenderness  on  pressure.  Warm, 
stimulating  foot-baths  are  highly  useful.  These  measures  relieve 
by  obviating  the  tendency  to  the  accumulation  of  blood  within  the 
heart.  This  tendency  is  shown  by  coldness  of  the  surface  and 
extremities  during  paroxysms  of  palpitation.  Painful  stimulation 
of  the  surface  is  also  useful  by  diverting  the  attention  of  the  patient 
from  the  heart.  If  an  opiate  be  not  employed,  the  remedies  called 
antispasmodic  are  indicated,  such  as  the  ethereal  preparations,  the 
compound  spirits  of  lavender,  the  aromatic  spirit  of  ammonia, 
valerian,  assafoetida,  etc.  Some  of  these  may  be  given  in  conjunc- 
tion with,  or  in  addition  to  opium  or  the  salts  of  morphia. 

In  paroxysms  characterized  by  feebleness  of  the  heart's  action, 
with  interraittency  and  a  tendency  to  syncope,  prompt  relief  is 
often  afforded  by  alcoholic  stimulants.  Brandy  or  some  form  of 
spirit  should  be  given  pretty  freely,  and  not  much  diluted.  Ano- 
dynes, antispasmodics,  and  revulsive  applications  may  be  added. 

The  symptoms  associated  with  palpitation,  exclusive  of  those 
referable  to  the  heart,  must  influence,  to  some  extent,  palliative 
measures.  Thus,  if  plethora  be  manifestly  present,  a  small  vene- 
section or  local  bloodletting  by  cupping  or  leeching,  may  be  indi- 
cated with  a  view  to  immediate  relief.  Marked  coldness  of  the 
surface,  on  the  other  hand,  and  prostration,  point  to  the  free  use  of 
stimulants.  Remedies  addressed  to  the  stomach,  in  certain  cases, 
are  effectual.  If  the  stomach  be  distended  with  gas,  carminatives 
sometimes  act  indeed  like  a  charm.  If  acidity  or  cardialgia  are 
present,  an  alkaline  or  antacid  remedy,  and  especially  ammonia, 
may  cut  short  the  paroxysm.  If  the  bowels  be  constipated  and 
flatulent,  an  active  cathartic,  or  a  large,  stimulating  enema  may 
prove  equally  efficient. 

In  paroxysms  occurring  in  persons  of  a  gouty  habit,  it  has  been 
advised  to  make  irritating  applications  to  the  joints  usually  affected, 
in  order  to  solicit  the  local  manifestations  of  the  disease  in  these 
situations.  Preparations  of  colchicum  and  guaiacum  are  considered 
as  indicated  by  palpitation  occurring  under  these  circumstances. 
The  palliative  measures,  however,  suited  to  other  cases  are  appli- 
cable, and  especially  remedies  addressed  to  the  stomach. 


CHAPTER    X. 

DISEASES  OF  THE  AORTA.— THORACIC  ANEURISMS. 

Acute  aortitis — Subacute  or  chronic  aortitis — Morbid  deposit  on  the  surface  of  the  lining 
membrane  of  the  aorta — Atheroma — Calcareous  deposit — Dilatation  of  the  ascending 
aorta — Thoracic  aneurisms — Definition — Varieties — Anatomical  relations,  etc. — Causes 
— Terminations — Symptoms — Physical  signs — Diagnosis — Treatment. 

Affections  of  the  aorta  do  not,  strictly,  fall  within  the  scope  of 
a  treatise  on  the  diseases  of  the  heart;  but  they  are  with  propriety 
included,  not  merely  on  account  of  the  close  anatomical  relations  of 
the  parts  affected,  but  because  diseases  in  these  two  situations  are 
often  associated,  and,  without  proper  knowledge  and  care,  certain 
symptoms  and  signs  due  to  aortic  affections,  are  liable  to  be  attri- 
buted to  the  heart.  The  aorta  may  be  the  seat  of  inflammation, 
acute  and  chronic,  and  of  structural  changes,  either  resulting  from 
inflammation,  or  non-inflammatory;  it  is  subject  to  alterations  in 
calibre,  viz.,  contraction  or  dilatation,  and  aneurisms  occur  oftener 
in  this  than  in  any  other  portion  of  the  arterial  system.  This 
chapter  will  be  devoted  to  a  brief  consideration  of  these  several 
forms  of  disease,  treating  of  them  only  so  far  as  they  are  of  interest 
to  the  practitioner  of  medicine. 

Acute  inflammation  of  the  aorta  is  one  of  the  most  infrequent  of 
diseases.  Only  a  small  number  of  well-marked  cases  are  on  record. 
It  might  naturally  be  presumed  that  the  inflammation  would  be 
likely  to  extend  into  this  artery,  from  the  left  ventricle,  in  endo- 
carditis, but  it  is  quite  otherwise ;  the  latter  disease  is  sufficiently 
common,  and  in  the  few  cases  of  aortitis  which  have  been  observed, 
it  does  not  appear  to  have  been  always  either  preceded  or  accom- 
panied by  endocardial  inflammation.  According  to  Eokitansky, 
and  other  late  pathologists,  the  primary  seat  of  inflammation  affect- 
ing the  arteries  is  in  the  outer,  or,  as  commonly  called,  the  cellular 
coat.  The  middle  and  lining  coats,  not  containing  bloodvessels, 
are  supposed  never  to  be  the  point  of  departure  of  inflammation,  but 
to  become  involved  secondarily  in  the   inflammatory  processes. 


430  DISEASES    OF    THE    AOKTA. 

Vascular  engorgement  is  presented  only  in  tlie  cellular  coat.  In- 
flammatory exudation,  and  pus,  either  infiltrated  or  collected  in 
small  abscesses,  may  be  here  found.  The  middle  and  lining  coats 
are  thickened  softened,  friable,  easily  detached  from  each  other,  and 
presenting  sometimes  appearances  resembling  ulceBations.  The 
redness  which  these  coats  may  present  is,  probably,  always  due  to 
the  imbibition  of  the  serum  of  the  blood  holding  in  solution  haematin. 
Solid  deposits  are  formed  within  the  vessel,  consisting  chiefly  of 
coagulated  fibrin,  or  decolorized  clots.  Whether  exuded  lymph  may 
permeate  the  middle  and  lining  tissues  and  accumulate  within  the 
artery,  is  a  point  on  which  pathologists  are  not  agreed.  These  de- 
posits, in  proportion  to  their  quantity,  must  diminish  the  calibre  of 
the  vessel,  and  obstruct  the  free  passage  of  blood.  They  may  be 
sufQcient  to  cause  occlusion  of  some  of  the  arterial  branches. 
Carried  onward  in  masses,  or  in  disintegrated  particles,  with  the 
current  of  blood,  they  may  occasion  obstruction  of  remote  vessels, 
and  interrupt  the  circulation  in  certain  portions  of  the  body,  possi- 
bly leading,  thereby,  to  gangrene. 

Acute  aortitis  is  not  attended  by  symptoms  distinctive  of  the 
disease ;  or,  at  all  events,  if  the  clinical  history  embrace  any 
peculiar  symptomatic  phenomena,  they  are  yet  to  be  ascertained. 
Disease  of  the  lungs  or  heart  coexisting  in  most  cases,  the  pheno- 
mena referable  to  the  surrounding  organs  render  obscure  sjanptoms 
proceeding  from  the  aortic  inflammation.  Association  with  various 
concomitant  morbid  conditions  will  serve  to  explain  the  discrepancy 
in  the  descriptive  history  of  different  cases  which  have  been  reported. 
It  is  doubtful  whether  acute  pain  ever  pertains  intrinsically  to  the 
disease.  Dr.  Corrigan  attributes  the  occurrence,  in  some  instances, 
of  painful  paroxysms  resembling  those  of  angina  pectoris,  to  in- 
flammation seated  at  the  origin  of  the  artery,  but  these  have  been 
only  occasionally  observed,  and  it  is  not  certain  that  there  was  any 
direct  pathological  connection  with  the  aortitis.  (Edema  of  the 
extremities  and  of  the  body  generally,  or  anasarca,  observed  by 
Bizot,  and  considered  by  him  as  characteristic  of  the  disease,  was 
probably  due  to  coexisting  Bright's  disease,  the  latter  afl'ection 
being  but  little  understood  at  the  time  his  observations  were  made. 
Febrile  movement,  more  or  less  intense,  doubtless  accompanies 
acute  inflammation  in  this  situation,  and  is  proportionate  to  the 
extent  of  the  aorta  involved.  It  is  intelligible  that  if  the  current 
of  blood  through  the  arteries  be  obstructed  by  the  accumulation  of 
coagula  or  lymph,  the  pulse  will  be  proportionately  small.     Feeble- 


INFLAMMATION    OF    AOETA.  431 

ness  of  the  pulse  must  also  be  an  effect  of  the  impaired  elasticity  of 
the  coats  of  the  artery.  It  is  probable  that  the  transportation  of 
fibrinous  plugs  with  the  current  of  blood  to  the  smaller  arteries, 
occurs  in  some  cases,  giving  rise  to  effects  which  have  been  noticed 
in  a  previous  chapter  under  the  head  of  embolia.* 

As  regards  physical  signs,  violent  pulsation  of  the  artery  is  said 
to  be  incident  to  inflammation.  It  is  possible  that  this  sign  may 
be  sometimes  appreciable  in  the  second  intercostal  space,  close  to 
the  sternum,  on  the  right  side,  where  the  artery  approaches  nearest 
the  thoracic  walls.  But,  as  an  isolated  sign,  this  is  not  distinctive 
of  aortitis.  The  artery  is  much  more  accessible  to  palpation  in  the 
epigastrium;  but  violent  pulsation  in  this  situation  is  sufficiently 
common  without  involving  inflammation.  In  a  case  observed  by 
Dr.  Parkes,  and  cited  by  Walshe,  a  loud,  rough  systolic  murmur 
was  audible  from  the  third  dorsal  vertebra  quite  down  to  the  lum- 
bar region.  The  production  of  a  murmur  in  consequence  of  the 
presence  of  deposits  of  fibrin  and  lymph  within  the  affected  vessel 
is  readily  understood;  but  structural  changes,  occurring  as  either 
effects  of  inflammation  or  of  non-inflammatory  processes,  equally 
give  rise  to  a  murmur,  so  that  this  can  only  be  considered  as  a  sign 
of  aortitis  when  developed  while  a  case  is  under  observation,  and 
associated  with  other  phenomena  rendering  the  existence  of  the 
disease  probable.  In  short,  physical  exploration  fails  in  furnishing 
definite  signs  upon  which  much  reliance  is  to  be  placed. 

From  the  preceding  remarks  relating  to  symptoms  and  signs  it 
follows  that  the  diagnosis  of  acute  aortitis,  in  the  present  state  of 
knowledge,  is  impracticable.  Hence  a  fuller  consideration  of  the 
disease,  including  the  subject  of  the  treatment,  would  be  incon- 
sistent with  the  practical  character  of  this  work. 

The  frequency  of  subacute  or  chronic  aortitis  is  problematical. 
If  the  anatomical  changes  so  often  found  within  the  aorta  are  of 
inflammatory  origin,  as  some  pathologists  have  assumed,  inflam- 
mation of  a  low  grade  of  intensity  must  be  quite  common  in  this 
situation.  In  many,  if  not  most,  instances,  it  is  probable  that  these 
changes  are  non  inflammatory ;  but  the  discussion  of  the  question, 
how  often  or  to  what  extent  they  involve  inflammation,  would  be 
unprofitable  in  a  practical  point  of  view,  and  therefore  here  out  of 
place.  Symptoms  and  physical  signs  do  not  furnish  the  means  of 
recognizing  subacute  or  chronic  aortitis  during  life. 

'  Chapter  IV.  page  151. 


432  DISEASES    OF    THE    AORTA. 

The  anatomical  changes  occurring  within  the  aorta,  to  which 
reference  has  just  been  made,  involve  the  presence  of  morbid 
deposit.  In  examining  the  bodies  of  aged  persons  after  death,  it  is 
rare  to  find  the  internal  surface  of  this  artery  entirely  free  from 
disease.  Changes  due  to  morbid  deposit  often  occur  in  the  middle 
aged,  especially  in  males;  and  they  are  sometimes  observed  in  young 
subjects.  They  are  found  when  there  had  been,  during  life,  no 
symptoms  denoting  disease  in  this  situation  ;  but  they  are  important 
as  leading  to  dilatation,  aneurism,  and  occasionally  perforation  or 
rupture.  Their  agency  in  the  production  of  certain  physical  signs 
is,  also,  to  be  borne  in  mind. 

The  deposit  may  be  situated  upon  the  free  surface  of  the  lining 
membrane  of  the  vessel,  forming  membraniform  patches,  variable 
in  number,  thickness,  and  size,  composed  of  a  white,  dense  sub- 
stance, sometimes  of  a  cartilaginous  firmness,  closely  adherent  to 
the  membrane.  This  substance  may,  possibly,  in  some  instances, 
be  lymph  which  has  exuded  from  the  vasa  vasorum  of  the  outer 
coat,  and  permeated  the  middle  and  inner  tunics  of  the  artery. 
According  to  Eokitansky,  it  is  always  derived  from  the  blood 
within  the  artery,  and  is  either  condensed  fibrin,  or  "an  excessive 
deposition  of  the  lining  membrane  of  the  vessels."  This  deposit  in 
some  cases  extends  over  the  whole  aorta,  and  even  into  the  com- 
municating arteries.  It  may  lead  to  occlusion  of  the  latter  at  the 
points  of  communication  with  the  aorta.  Although  this  false  mem- 
brane becomes,  after  a  time,  so  closely  adherent  to  the  surface  of 
the  inner  coat  of  the  artery  that  it  cannot  be  removed  without 
bringing  away  the  latter,  it  is  not  united  by  means  of  an  organized 
attachment,  and  does  not  itself  take  on  organization. 

A  more  common  form  of  deposit  is  that  known  as  atheroma.  This 
deposit  takes  place  beneath  the  lining  membrane  of  tlie  artery.  It 
occurs  first  in  small,  isolated  points  which  increase  and  coalesce, 
forming  patches  of  greater  or  less  size.  The  substance  of  the  de- 
posit is  soft  and  even  semi-liquid,  or  more  or  less  hard.  It  is  found, 
on  microscopical  examination,  to  contain  oii-globules  in  abundance 
with  crystals  of  cholesterine,  and,  hence,  it  is  considered  as  consti- 
tuting a  variety  of  fatty  degeneration.  It  is  frequently  associated 
with  fatty  change  of  the  muscular  substance  of  the  heart  to  a  greater 
or  less  extent.  The  presence  of  this  deposit  involves  more  or  less 
softening  and  looseness  of  the  middle  and  lining  coats  of  the  artery. 
The  atheromatous  deposit  is  the  seat  of  the  calcareous  matter  so 
often  observed  in  the  bodies  of  those  who  die  after  the  middle 


CALCAREOUS    DEGENERATION    OF    AORTA.  433 

period  of  life,  not  infrequently  occurring  during,  and  sometimes 
prior  to,  this  period.  In  the  progress  of  time,  the  patches  of  athe- 
roma are  transformed  into  plates  or  masses  of  a  bony  hardness. 
The  lining  membrane  of  the  artery  covering  these  plates  or  masses 
disappears,  and  they  project  into  the  vessel,  coming  in  direct  con- 
tact with  the  current  of  blood.  The  interior  surface  of  the  vessel 
is  in  this  way  roughened  ;  the  current  of  blood  is  broken,  and  the 
elasticity  of  the  artery  impaired  or  destroyed.  The  projections 
within  the  vessel  also  serve  as  a  nucleus  for  the  deposit  of  fibrin, 
and  the  calibre  of  the  vessel  may  thus  be  considerably  diminished, 
causing  obstruction  to  the  free  passage  of  the  blood.  The  trans- 
formation of  atheromatous  into  calcareous  patches,  must  be  con- 
sidered as  a  conservative  provision  for  strengthening  the  affected 
portions  of  the  artery,  diminishing  the  liability  to  dilatation  and 
rupture.  If,  however,  the  vessel  be  extensively  calcified,  and  ren- 
dered thereby  unyielding  and  inelastic,  the  circulation  is  deprived 
of  the  force  derived  from  the  recoil  of  the  affected  portion  of  the 
aorta ;  an  additional  labor  falls  upon  the  left  ventricle  which,  in 
consequence,  is  apt  to  become  hypertrophied.  Calcified  arteries 
were  formerly  said  to  be  ossified,  and  the  term  ossification  is  still 
sometimes  applied  to  this  morbid  change,  incorrectly,  inasmuch  as 
the  calcareous  deposit  fecks  the  characters  of  bony  texture,  resem- 
bling the  latter  only  in  density  and  chemical  composition. 

Calcareous  degeneration  may  exist  to  a  considerable  extent  without 
giving  rise  to  any  notable  symptoms  of  disease.  It  is  found  after 
death  to  pervade  the  aorta  more  or  less  extensively,  especially  at 
and  anterior  to  the  arch,  having  occasioned,  during  life,  no  apparent 
inconvenience.  But  it  may  give  rise  to  aortic  murmurs  which  it  is 
desirable  to  discriminate  from  those  involving  lesions  of  the  aortic 
valves  and  orifice.  With  these  lesions,  affections  of  the  aorta  are 
frequently  associated,  but  the  artery  may  be  extensively  diseased 
without  the  valves  and  orifice  being  involved.  How  is  this  fact  to 
be  determined  during  life?  The  friction  of  the  current  of  blood  in 
its  onward  course  against  the  inner  surface  of  the  aorta  roughened  by 
calcareous  patches,  causes  a  murmur;  and  the  regurgitant  current 
or  retrograde  movement  of  the  column  of  blood,  due  to  the  recoil 
of  the  arterial  coats,  may  also  cause  a  murmur,  even  assuming  that 
the  semilunar  valves  are  sufficient.  We  may  thus  have  a  sj^stolic 
and  a  diastolic  murmur,  one  or  both,  produced  within  the  aorta, 
independently  of  either  obstruction  or  insufficiency  at  the  aortic 
orifice.  It  is  desirable  to  distinguish  these  murmurs,  for  they 
28 


434  DISEASES    OF    THE    AORTA. 

represent  lesions  wliich  are  of  little  consequence  compared  with 
those  involving  aortic  contraction  and  regurgitation,  and,  conse- 
quently, serious  enlargement  of  the  heart.  A  systolic  murmur 
produced  within  the  artery  just  above  the  orifice,  may  have  its 
maximum  of  intensity  in  the  second  intercostal  space  close  to  the 
sternum,  where  the  artery  is  nearest  the  ear  of  the  auscultator. 
In  this  respect  it  does  not  differ  from  a  murmur  produced  at  the 
aortic  orifice.  It  is  less  likely  than  the  latter  murmur  to  extend 
below  the  level  of  the  third  rib.  It  is  perhaps  more  likely  to  be 
propagated  with  considerable  intensity  into  the  carotids.  These 
differential  points,  it  must  be  confessed,  are  not  sufficient  always 
for  a  positive  discrimination.  The  aortic  second  sound  of  the  heart 
is  to  be  taken  into  consideration.  This  sound  is  not  likely  to  be 
notably  impaired  if  the  aortic  orifice  be  not  the  seat  of  lesions.  At 
all  events,  an  aortic  murmur,  whether  produced  at  the  orifice,  or 
within  the  artery  above,  does  not  necessarily  denote  a  serious 
morbid  condition,  when  the  aortic  second  sound  is  unimpaired. 
A  diastolic  murmur  produced  within  the  artery  above  the  orifice, 
provided  the  semilunar  valves  be  sufficient,  is  heard  in  the  second 
and  third  intercostal  spaces  on  the  right  side  of  the  sternum.  It  is 
not  propagated  downward,  as  when  it  is  produced  by  regurgitation 
through  the  aortic  orifice  into  the  cavity  of  the  ventricle,  the  valves 
being  insufficient.  In  the  latter  case,  the  murmur  is  loudest  over 
the  body  of  the  heart  and  is  heard  often  at  the  xiphoid  cartilage,  or 
even  still  lower.  The  integrity  of  the  aortic  second  sound  of  the 
heart  is  important  in  determining  that  a  diastolic  murmur  is  pro- 
duced within  the  artery  alone,  without  involving  insufficiency  and 
regurgitation  at  the  aortic  orifice.  If  the  aortic  second  sound  be 
not  notably  impaired,  it  may  be  assumed  that  the  murmur  is  pro- 
duced within  the  artery.  It  is,  however,  to  be  considered  that  in 
proportion  as  the  elasticity  of  the  aorta  is  diminished,  the  intensity 
of  the  aortic  second  sound  will  be  lessened.  It  is  to  be  added,  that 
the  intensity  or  quality  of  a  murmur  produced  within  the  aorta,  is 
not  evidence  of  the  extent  or  amount  of  disease.  Calcareous  patches, 
few  and  small,  may  so  roughen  the  membrane  as  to  develop  a 
loud  rasping  murmur;  and,  on  the  other  hand,  calcareous  deposit 
may  pervade  the  artery  when  the  murmur  is  feeble  and  soft,  the 
physical  conditions,  in  the  latter  case,  being  less  favorable  for  the 
production  of  sonorous  vibrations.  Much  will  depend  on  the 
power  with  which  the  left  ventricle  contracts,  as  regards  the  loud- 
ness and  roughness  of  aortic  murmurs;  hence,  other  things  being 


DILATATION    OF    THE    AORTA.  435 

equal,  they  are  loud  and  rougli  in  proportion  to  the  amount  of 
hypertrophy  of  this  ventricle  which  may  be  present,  and  the  mus- 
cular vigor  of  the  heart. 

Dilatation  of  the  ascending  aorta  is  a  not  infrequent  result  of 
atheromatous  and  calcareous  disease.  The  middle  and  lining  tunics 
becoming  softened,  attenuated,  and  the  elasticity  of  the  vessel  im- 
paired or  lost,  dilatation  takes  place  from  the  distending  force  of 
the  blood-currents  propelled  forward  by  the  systole  of  the  left  ven- 
tricle, and  backward  by  the  recoil  of  the  arterial  coats  beyond  the 
affected  portion  of  the  aorta.  This  result  is  more  apt  to  follow  if 
the  left  ventricle  become  hypertrophied.  The  ascending  portion  of 
the  arch  and  the  sinuses  of  Valsalva  are  the  points  most  apt  to 
yield  to  the  distension.  In  the  latter  situation,  the  dilatation  is 
probably  produced  more  by  the  retrograde  than  the  onward  cur- 
rent, provided  the  semilunar  valves  remain  sufficient.  According 
to  Dr.  Bellingham,  visible  pulsation  of  the  large  arteries  of  the  neck 
and  upper  extremities,  and  a  jerking  or  receding  pulse,  are  charac- 
teristic of  dilatation  of  the  arch  of  the  aorta.  These  signs  have 
been  noticed  in  a  previous  chapter  as  distinctive  of  lesions  at  the- 
aortic  orifice  permitting  regurgitation  from  the  artery  into  the  left 
ventricle.  Their  significance  of  dilatation  of  the  aorta,  disconnected 
from  aortic  insufficiency,  must  depend  on  the  presence  of  adequate 
evidence  that  the  semilunar  valves  remain  sufficient.  This  evidence 
consists  in  the  absence  of  a  murmur  denoting  regurgitation  into 
the  ventricle,  and  the  intensity  of  the  aortic  second  sound  of  the 
heart  being  but  little,  if  at  all  impaired.  It  is  only  under  these 
conditions  that  the  signs  can  be  considered  as  indicating  aortic 
dilatation.  Dr.  Bellingham  also  states  that  an  impulse  synchronous 
with  the  pulse  is  perceived  when  the  ear  is  applied  to  the  stethoscope 
laid  upon  the  first  bone  of  the  sternum.  This  impulse  may  be  per- 
ceived thus  by  the  ear  when  it  is  not  communicated  to  the  hand 
with  sufficient  force  to  be  appreciable.  In  connection  with  these 
signs,  a  double  rough  murmur  is  perceived  which  is  referable  to 
the  aorta  and  not  to  the  aortic  orifice.  The  diagnosis  in  some  cases, 
as  claimed  by  the  author  just  mentioned,  may  be  made  out  by 
means  of  this  combination  of  physical  signs;  but  in  most  cases, 
the  diagnostic  points  are  invalidated  by  the  coexistence  of  lesions 
at  the  aortic  orifice. 

The  foregoing  diseases  of  the  aorta,  although  intrinsically  im- 
portant, and  involving  pathological  questions  of  much  interest, 
have  been  passed  over  cursorily,  because  the  diagnosis  is  generally 


486  THORACIC    ANEURISMS. 

impracticable,  and,  were  it  practicable,  they  are,  for  the  most  part, 
not  amenable  to  treatment.  Acute  aortitis,  if  ascertained,  would 
call  for  measures  to  diminish  the  intensity  of  inflammation  and  the 
tendency  to  coagulation  of  the  fibrin  in  the  blood.  Subacute  or 
chronic  aortitis  is  always  latent,  ^nd  it  is  doubtful  whether,  were 
its  existence  determined,  therapeutical  measures  would  be  of  much 
avail.  Atheromatous  deposit  is  not  revealed  either  by  symptoms 
or  signs,  and  is  dependent  on  a  diathesis  often  incident  to  age,  and 
the  removal  of  which  could  hardly  be  expected.  Calcareous  plates 
or  masses,  and  dilatation  of  the  aorta,  give  rise  to  murmurs  which, 
with  proper  attention  and  knowledge,  may,  in  some  instances,  be 
referred  to  the  aorta.  The  latter  is  the  most  important  practical 
point  connected  with  the  aortic  diseases  which  have  been  noticed. 
Murmurs,  systolic  and  diastolic,  may  be  generated  by  the  currents 
of  blood  exclusively  within  the  aorta,  when  the  lining  membrane 
is  roughened  by  calcareous  matter  or  other  structural  changes  such 
as  puckering  of  the  membrane,  and  by  alterations  in  the  calibre  of 
the  vessel.  These  murmurs,  if  incorrectly  referred  to  the  aortic 
orifice,  would  denote  serious  lesions,  whilst,  in  fact,  the  anatomical 
changes  are  comparatively  unimportant,  and  perhaps  innocuous. 
This  is  to  be  borne  in  mind,  and  it  is  to  be  determined,  if  prac- 
ticable, in  individual  cases,  whether  aortic  murmurs  are  produced 
•within  the  artery  or  at  the  aortic  orifice.  Owing  to  the  frequent 
coexistence  of  lesions  situated  at  this  orifice  with  diseases  of  the 
aorta,  murmurs  are  often  developed  in  both  situations.  Under 
these  circumstances,  the  discrimination  is  difficult,  and  compara- 
tively of  small  importance. 

The  subject  of  thoracic  aneurisms  claims  a  more  extended  con- 
sideration than  the  aortic  diseases  which  have  been  noticed.  To 
this  subject,  the  remainder  of  the  chapter  will  be  devoted. 


THORACIC    ANEURISMS. 


The  term  aneurism,  in  its  broadest  sense,  and  in  accordance  with 
its  etymology,'  is  applicable  to  every  species  of  dilatation  of  an 
arterial  trunk.  It  is  convenient,  however,  to  exclude  cases  in 
which  an  artery  is  slightly  or  moderately  enlarged  in  its  whole 

'  a.\iivfV7fJi,a.,  a  dilatation. 


VARIETIES    OF    ANEURISM.  437 

circumference,  confining  the  application  of  the  term  to  dilatations 
of  this  description  which  are  considerable  in  degree,  and  circum- 
scribed, as  regards  the  extent  of  the  vessel  affected.  But  the  term 
is  applied  more  particularly  to  dilatations  of  a  portion  of  the  arte- 
rial wall,  forming  a  sac  or  pouch  of  greater  or  less  size.  Writers 
treating  at  length  of  this  subject  have  divided  aneurisms  into 
various  kinds,  according  to  the  form  of  the  enlargement,  the 
integrity,  or  otherwise,  of  the  several  coats  of  the  artery,  etc. 
Thus,  if  the  dilatation  affect  the  entire  circumference  of  the  vessel, 
the  dilated  portion  is  in  some  instances  cylindrical,  and  in  other 
instances  fusiform  or  spindle-shaped ;  hence  a  division  after  these 
two  forms.  The  division  into  true  and  false  aneurisms  has  been 
long  maintained,  in  the  former  the  artery  being  simply  dilated 
without  solution  of  continuity  in  any  of  the  coats,  in  the  latter  the 
inner  and  middle  coats-  having  been  ruptured  or  destroyed  over  a 
certain  space.  True  aneurisms,  according  to  this  distinction,  pre- 
sent the  same  number  of  tunics  as  the  artery  in  its  healthy  state, 
whilst  in  a  false  aneurism,  the  sac  or  pouch-like  dilatation  consists, 
either  entirely  or  in  part,  of  only  the  external  coat  of  the  artery. 
The  breach  in  the  middle  and  lining  tunics  may  be  the  point  of 
departure  for  the  aneurismal  dilatation.  It  is  so  considered  by 
most  writers  in  the  majority  of  cases,  but  this  is  denied  by 
Rokitansky,  who  thinks  that  the  destruction  of  these  coats  is  gene- 
rally consecutive  to  the  dilatation.  In  the  instances  in  which  the 
latter  is  assumed,  the  aneurism  is  said  to  be  mixed.  A  mixed  aneu- 
rism, then,  is  one  which,  being  primarily  true,  in  its  progress 
becomes  false.  The  tumor  formed  by  an  aneurismal  sac  is  gene- 
rally smooth  and  globular,  but  it  is  sometimes  oval  or  conical  in 
shape,  and  may  be  rendered  irregular  by  secondary  and  even 
tertiary  dilatations  giving  it  a  mulberry  appearance  externally, 
and  causing  it  to  present  internally  a  multilocular  arrangement. 
These  variations  have  given  rise  to  other  divisions.  A  curious 
variety  is  called  the  dissecting  aneurism.  In  this  kind,  rupture  of 
the  inner  and  middle  coats  of  the  artery  first  occurs,  and  the  blood, 
instead  of  dilating  the  outer  coat  so  as  to  form  a  sac,  detaches  this 
coat  over  a  greater  or  less  distance.  In  an  instance  reported  by 
Dr.  Pennock,^  the  dissection  of  the  coats  extended  as  far  as  the 
primitive  iliacs.     The  aorta  in  this  case  presented  the  appearance 

'  Note  in  Hope  on  Diseases  of  tlie  Heart,  1842,  p.  402.  Several  cases  are  here 
reported  by  the  editor,  Dr.  Pennock.  Similar  cases  have  been  described  by 
Laennec,  Guthrie,  and  others. 


438  THORACIC    ANEURISMS. 

of  a  double  cylinder,  that  situated  internally  being  the  aorta 
proper,  communicating  directly  with  the  heart,  and  surrounding 
this  a  much  larger  cylinder  communicating  with  the  inner  one  by 
a  valvular  fissure  half  an  inch  in  length.  In  some  instances  the 
blood  which  separates  the  coats,  after  passing  a  certain  distance, 
finds  its  way  again  into  the  proper  arterial  channel  through  a 
second  opening. 

An  account  of  each  of  the  various  kinds  of  aneurism  should,  of 
course,  enter  into  a  full  consideration  of  the  subject ;  but,  directing 
attention  exclusively  to  aneurisms  of  the  thoracic  aorta,  and  con- 
sidering these  only  so  far  as  they  are  of  interest  to  the  diagnosti- 
cian, the  kinds  which  are  distinguished  as  sacculated  are  chiefly 
important  in  the  present  connection.  Sacculated  aneurisms  giving 
rise  to  symptoms  and  signs  upon  which  a  diagnosis  may  be  based, 
in  the  great  majority  of  cases,  are  either  false  or  mixed  aneurisms. 
With  reference  to  diagnostic  phenomena,  certain  points  relating  to 
sacculated  aneurisms  are  to  be  kept  in  view.  These  points  are  to 
be  noticed  prior  to  considering  the  symptoms  and  physical  signs. 

Sacculated  thoracic  aneurisms  form  tumors  varying  in  size  from 
a  pea  to  the  foetal  head,  but  to  give  rise  to  phenomena  available 
for  diagnosis,  the  size  must  be  considerable.  Their  situation  deter- 
mines,  to  a  considerable  extent,  their  symptoms  and  signs.  They 
are  seated  oftenest  in  the  ascending  aorta,  next  in  frequency  at  the 
arch,  and  less  frequently  in  the  descending  aorta.  Of  eighty-seven 
cases,  in  forty  they  were  connected  with  the  ascending  aorta,  in 
thirty  with  the  arch,  and  in  sixteen  with  the  descending  portion.' 
They  occur  not  infrequently  at  the  sinuses  behind  the  semilunar 
valves,  and  in  this  situation  rupture  takes  place  before  the  tumor 
attains  to  a  large  size,  in  consequence  of  the  cellular  coat  which 
exists  in  other  situations  being  here  wanting  and  its  place  supplied 
by  the  more  delicate  pericardium.  The  efl'usion  of  blood  when 
rupture  takes  place  is  into  the  pericardial  sac,  and  death  is  usually 
produced  almost  immediately  by  mechanical  compression  of  the 
heart.  The  diagnosis  of  aneurism  in  this  situation  is  impossible. 
Of  two  cases  that  have  fallen  under  my  observation,  in  one  the 
patient  fell  and  expired  almost  instantly  while  in  the  act  of  leaving 
the  hospital  after  recovering  from  an  attack  of  pleurisy.  In  the 
other  instance  the  person  was  found  dead,  having  been,  up  to  the 
time  of  death,  apparently  in  perfect  health.     In  neither  case  were 

'  Swett,  op.  cit.,  page  5rl4. 


ANATOMICAL    EELATIONS    OF   THOEACIC    ANEURISMS.     439 

there  any  symptoms  pointing  to  the  heart  or  large  vessels  as  the 
seat  of  disease.  Situated  above  the  valves,  the  aneurism  may  or 
may  not  be  accompanied  by  dilatation  of  the  artery  at  its  orifice, 
so  as  to  render  the  valves  insnflficient;  or  the  aneurism  may  or  may 
not  be  complicated  with  aortic  valvular  lesions.  As  regards  the 
effects  upon  the  heart,  much  depends  on  the  existence  or  nou-exist- 
ence  of  aortic  regurgitation.  If  regurgitation  take  place,  enlarge- 
ment of  the  heart,  commencing  and  predominating  in  the  left 
ventricle,  is  sure  to  follow;  but  if  the  aortic  valves  remain  suffi- 
cient, the  heart  by  no  means  invariably  becomes  enlarged.  Aneu- 
risms of  the  ascending  aorta  and  arch  are  generally  seated  on  the 
convex  side  of  the  vessel,  and  the  tumor  extends  from  the  vessel  in 
a  direction  to  the  right,  the  distance,  of  course,  being  proportionale 
to  the  size  of  tlie  tumor.  But  it  is  to  be  borne  in  mind  that  the 
tumor  may  spring  from  the  concave  or  the  posterior  surface  of  the 
vessel  and  extend  in  different  directions,  having,  consequently, 
different  anatomical  relations  to  the  thoracic  walls  and  the  organs 
within  the  chest.  Whatever  may  be  the  direction  in  which  the 
tumor  extends,  in  proportion  to  its  size,  it  presses  npon  surrounding 
parts,  displaces  them,  interfering  with  the  performance  of  their 
functions;  it  gives  rise  to  local  inflammation  and  abnormal  adhe- 
sions, causes  erosion  and  atrophy  of  organized  structures,  and, 
finally,  ends  frequently  in  rupture  or  an  opening  produced  by 
sloughing  or  ulceration,  through  which  the  arterial  blood  escapes 
either  externally  or  into  some  internal  part. 

The  anatomical  relations  of  aneurismal  tumors  must  be  con- 
sidered in  order  to  understand  the  rationale  of  certain  symptomatic 
phenomena.  Arising,  in  the  majority  of  cases,  from  the  convex 
margin  of  the  ascending  aorta  or  the  arch,  contracting  adhesions 
with  the  thoracic  walls,  and  erosion  of  the  latter  taking  place,  the 
integuments  are  at  length  raised,  forming  a  visible  swelling.  This 
swelling  or  external  tumor  is  generally  situated  at  a  point  on  the 
right  side  of  the  sternum  between  the  clavicle  and  the  fifth  or  sixth 
ribs;  but  it  may  make  its  appearance  over  the  first  or  second  bones 
of  the  sternum,  or  in  the  neck,  or  below  the  left  clavicle,  and  in 
rare  instances  on  the  posterior  surface  of  the  chest.  But  before  it 
becomes  apparent  to  the  eye,  certain  effects  are  apt  to  be  produced 
by  pressure  on  internal  parts.  These  effects  are  still  more  marked 
when  the  aneurismal  tumor  springs  from  the  concave  margin  of 
the  vessel.  The  parts  exposed  to  pressure,  and  giving  rise  to 
symptomatic  phenomena,  are  the  trachea,  the  bronchi,  the  lungs, 


440  THORACIC    ANEURISMS. 

the  oesophagus,  the  par  vagum  and  recurrent  nerves,  the  superior 
vena  cava,  the  thoracic  duct,  and  the  pulmonary  artery.  The 
eJBPects  of  pressure  on  these  parts  belong  among  the  symptoms  of 
thoracic  aneurism.  The  anatomical  relations  of  aneurismal  tumors 
arising  from  the  descending  aorta  are  diflerent.  Pressure  on  the 
parts  just  mentioned  does  not  occur.  An  external  tumor  is  not 
developed  unless  the  aneurism  become  extremely  large.  They  are 
apt  to  contract  adhesions  to  the  dorsal  vertebrse,  leading  to  erosion 
of  the  bony  structure,  and  sometimes  an  opening  takes  place  into 
the  spinal  canal.  Situated  behind  the  heart,  an  aneurismal  tumor 
may  displace  this  organ,  and,  by  pressing  it  forward,  render  its 
action  on  the  thoracic  walls  so  strong  as  to  simulate  hypertrophy. 

•In  addition  to  the  size  of  aneurismal  tumors,  the  portion  of  the 
aorta  from  which  they  spring,  and  the  direction  in  which  they  ex- 
tend, other  points  are  concerned  in  the  production  of  symptoms 
and  signs.  The  mouth  of  the  sac  varies  in  size  and  form  in  differ- 
ent cases,  allowing  more  or  less  freedom  of  the  ingress  and  esrress 
of  blood,  and  either  favoring,  or  otherwise,  the  force  of  the  current 
into  the  cavity.  The  opening  may  be  smooth,  or  roughened  by 
calcareous  deposit.  The  artery  in  the  vicinity  of  the  aneurism  may 
be  healthy,  but  oftener  it  is  more  or  less  diseased.  The  interior  of 
the  sac  is  frequently  studded  with  calcareous  plates.  The  cavity 
of  the  sac  may  be  filled  with  liquid  blood ;  but  it  often  contains 
solidified  fibrin  in  more  or  less  abundance.  This  fibrin,  deposited 
in  a  series  of  concentric  layers,  presents  a  stratified  arrangement, 
the  layers  nearest  the  parietes  of  the  sac  being  the  most  condensed, 
decolorized,  and  dry,  and  those  in  proximity  to  the  blood  softer, 
more  moist,  and  reddened  with  haematin.  The  size  of  the  cavity 
receiving  blood  is,  of  course,  diminished  in  proportion  to  the  accu- 
mulation of  solidified  fibrin.  This  deposit  is  favored  by  the  large 
size  of  the  sac,  the  smallness  of  its  mouth,  roughness  of  the  interior 
surface,  and  feebleness  of  the  heart's  action.  It  must  be  considered 
as  a  conservative  provision  for  strengthening  the  sac  and  retarding 
the  progressive  increase  of  the  tumor.  A  spontaneous  cure  is 
sometimes  effected  by  an  accumulation  of  fibrin  sufficient  to  obli- 
terate the  cavity.  Masses  of  fibrin  are  liable  to  become  detached 
from  within  the  sac,  forming  emboli,  or  plugs,  which  are  carried 
onward  with  the  current  of  blood,  and,  becoming  impacted  in  arte- 
ries more  or  less  remote,  occasion  obstruction  of  the  circulation, 
and  the  consequences  of  a  diminished  supply  of  blood  to  important 
parts.     Obstruction  of  arterial  branches  communicating  with  the 


FORMATION    OF    THORACIC    ANEURISMS.  441 

portion  of  the  aorta  where  the  aneurism  is  seated,  is  an  important 
eifect.  This  arises  from  the  deposit  of  fibrin,  and  from  the  small 
size  of  the  mouth  of  the  sac,  or  the  form  of  the  aperture  being 
such  as  not  to  allow  free  passage  of  blood  into  the  cavity.  It  may 
also  proceed  from  the  outward  pressure  of  the  aneurismal  tumor. 
The  carotid  and  subclavian  arteries  may  in  this  way  be  more  or 
less  obstructed,  and  even  obliterated,  when  aneurisms  involve  the 
arch  of  the  aorta. 

The  formation  of  a  thoracic  aneurism  always  involves  a  pre-ex- 
istinsr  morbid  condition  of  the  arterial  coats,  and  in  most  instances 
this  morbid  condition  is  connected  with  the  atheromatous  deposit. 
The  middle  and  lining  coats  becoming  softened,  distensible,  and 
sometimes  destroyed  over  a  certain  space,  dilatation  is  produced 
by  the  force  of  the  blood-current,  and,  as  a  rule,  the  yielding  parts 
are  more  and  more  dilated  by  the  same  force.  Various  circum- 
stances, which  are  sufficiently  obvious,  on  the  one  hand  favor,  and 
on  the  other  hand  retard  the  progressive  increase  of  the  aneurismal 
tumor.  Other  things  being  equal,  the  increase  in  size  goes  on  with 
a  rapidity  proportionate  to  the  softened,  relaxed  state  of  the  sac, 
the  freedom  of  communication  with  the  artery,  the  power  of  the 
heart's  action,  and  the  deficiency  of  layers  of  fibrinous  deposit. 
These  circumstances  varying  in  different  cases,  the  progress  of 
aneurisms  is  sometimes  extremely  slow,  and  in  other  cases  com- 
paratively rapid.  The  connection  of  atheromatous  disease  is  to  be 
borne  in  mind,  for  its  existence  in  portions  of  the  artery  not  in- 
volved in  the  aneurism  may  give  rise  to  arterial  murmurs,  which 
have  been  already  considered ;  and  this  disease  is  apt  to  be  asso- 
ciated with  valvular  lesions  and  cardiac  enlargement,  irrespective 
of  the  effects  of  the  aneurism  on  the  heart. 

The  primary  causes  of  aneurism  affecting  the  aorta  are  those 
involved  in  the  production  of  disease  of  the  coats  of  this  vessel. 
The  supposed  agency  of  muscular  exertions  or  strains  in  certain 
cases,  irrespective  of  disease  of  the  artery,  may  fairly  be  doubted. 
An  influence  apparently  belongs  to  age  and  sex.  Males  are  far 
more  subject  to  the  affection  than  females,  and  it  is  rare  that  it 
occurs  prior  to  the  age  of  thirty  or  after  the  age  of  sixty.  These 
facts  are  explained  by  the  more  frequent  occurrence  of  disease  of 
the  coats  of  the  artery  in  males  than  in  females,  by  the  infrequency 
of  its  occurrence  prior  to  the  age  of  thirty  and  by  the  rigidity  of  the 
arterial  walls  and  lessened  power  of  the  heart  after  sixty.  The  fact 
that  the  ascending  aorta  and  the  arch  are  especially  apt  to  be  the 


442  THORACIC    ANEURISMS. 

seat  of  atheromatous  disease,  explains,  in  a  great  measure,  the 
liability  of  these  portions  of  the  aorta  to  become  afi'ected  with 
aneurism.  Aneurisms  seated  in  the  smaller  arterial  trunks  are 
frequently  of  traumatic  origin,  but  it  is  obvious  that  aneurisms  of 
the  aorta  are  never  attributable  to  wounds  of  this  vessel.  It  is 
possible  that  hypertrophy  of  the  left  ventricle  may  contribute  to 
the  formation  of  aneurism,  especially  when  seated  in  the  ascending 
aorta  and  arch,  in  consequence  of  the  abnormal  force  with  which 
the  blood  is  driven  into  the  artery. 

The  terminations  of  thoracic  aneurisms  may  be  briefly  noticed, 
before  entering  on  the  consideration  of  the  symptoms,  signs,  and 
diagnosis.  A  fatal  result  occurs  sooner  or  later  in  the  vast  ma- 
jority of  cases.  The  different  modes  in  which  this  result  is  brought 
about  are  of  historical  rather  than  practical  interest,  since  the}^  are 
influenced  but  little,  if  at  all,  by  remedial  interference. 

Eventually,  in  a  large  proportion  of  cases,  the  aneurismal  sac  opens, 
and  the  patient  dies  from  hemorrhage.  But  in  some  instances,  pres- 
sure on  important  parts,  viz.,  the  trachea,  bronchi,  lungs,  oesophagus, 
spinal  cord,  vena  cava  and  pulmonary  artery,  occasions  death  before 
rupture  takes  place.  Death  may  sometimes  be  attributable  to 
emboli  detached  from  within  the  sac.  It  is  needless  to  say  that  the 
existence  of  aneurism  does  not  preclude  the  development  of  various 
intercurrent  affections  which  may  destroy  life.  The  rupture  of  the 
aneurismal  sac  takes  place  in  different  situations.  It  occurs  within 
the  pericardium,  as  already  mentioned,  when  the  aneurism  is  seated 
below  the  attachment  of  this  membrane.  It  also  occurs  in  this 
situation,  occasionally,  when  the  site  of  the  aneurism  is  above  the 
attachment  of  the  membrane.  The  latter  occurred  in  five  of  seventy- 
nine  cases  analyzed  by  Mr.  Crisp  and  Dr.  Swett.  The  relative  fre- 
quency of  rupture  in  other  situations  will  be  most  readily  represented 
by  giving  the  combined  results  of  the  statistics  furnished  by  the 
authors  just  named.  Rupture  into  the  cavities  of  the  heart  took  place 
in  nine  of  one  hundred  and  thirty-eight  cases.  Of  these  nine  cases, 
the  rupture  was  into  the  right  auricle  in  four,  the  right  ventricle  in 
four,  and  the  left  ventricle  in  one.  Rupture  into  the  jjulmonanj 
artery  took  place  in  six  of  two  hundred  and  seventeen  cases.  In  all 
of  these  six  cases,  the  aneurism  was  seated  in  the  ascending  aorta  or 
arch.  Rupture  into  the  vena  cava  occurred  also  in  six  of  two  hun- 
dred and  seventeen  cases.  Rupture  into  the  pleural  sac  took  place  in 
fourteen  of  two  hundred  and  seventeen  cases.  Aneurisms  of  the 
descending  aorta  are  more  likely  to  open  in  this  situation  than 


TERMINATIONS    OF    THORACIC    ANEURISMS.  443 

those  seated  in  the  ascending  portion  or  the  arch.  The  rupture  is 
oftener  into  the  left  than  into  the  right  pleural  cavity.  Rupture 
into  the  Jung  occurred  in  eleven  of  two  hundred  and  fifty-four  cases. 
Rupture  into  the  oesophagus  took  place  in  sixteen  of  two  hundred 
and  sixty-two  cases.  When  it  occurs  in  this  situation  the  aneurism 
is  generally  seated  in  the  transverse  or  descending  portions  of  the 
aorta.  Rupture  into  the  trachea  took  place  in  thirteen  of  two  hun- 
dred and  fifty-four  cases.  The  aneurisms  in  these  cases  were  gene- 
rally seated  at  the  arch.  Rupture  into  a  bronchus  took  place  in  eight 
of  two  hundred  and  fifty-four  cases.  It  occurred  oftener  in  the  left 
than  in  the  right  bronchus.  Of  rupture  into  the  vertehral  ca7ml,  only 
a  single  instance  is  contained  among  the  cases  analyzed.  Rupture 
externally  took  place  in  only  eight  of  two  hundred  and  sixty-two 
cases.  It  is  thus  seen  that  the  instances  in  which  the  opening  takes 
place  into  some  internal  part,  greatly  preponderate  over  those  in 
which  the  rupture  is  external ;  of  two  hundred  and  sixty-two  cases 
analyzed,  internal  rupture  took  place  in  one  hundred  and  forty-five. 
As  already  stated,  rupture  is  a  termination  in  a  large  proportion  of 
cases ;  but  the  number  of  cases  in  which  death  occurs  either  from 
results  of  the  aneurism  irrespective  of  rupture,  or  from  intercurrent 
affections,  is  nevertheless  considerable.  Of  two  hundred  and  fifty 
fatal  cases,  in  ninety-two  rupture  did  not  take  place.  Finally,  a 
spontaneous  cure  of  thoracic  aneurism  is  possible.  It  can  take 
place  in  but  one  way,  which  has  been  already  mentioned,  viz.,  the 
obliteration  of  the  aneurismal  cavity  by  means  of  the  deposit  of 
fibrin.  Recovery,  however,  occurs  in  so  small  a  number  of  instances, 
that  the  possibility  of  its  occurrence  is  hardly  to  be  taken  into 
account  in  the  prognosis.  It  is  hardly  possible  after  the  aneurismal 
tumor  has  attained  to  a  large  size.  After  a  spontaneous  cure  has 
taken  place,  the  sac,  filled  with  fibrin,  and  remaining  attached  to 
the  artery,  presents  the  appearance  of  an  extraneous  tumor.  Obso- 
lete aneurisms  were  regarded  as  tumors  formed  without  the  artery, 
by  Corvisart  and  others,  prior  to  the  researches  of  Hodgson.  They 
doubtless  undergo  considerable  reduction  in  size  in  the  progress  of 
time,  from  contraction  of  the  contained  fibrin. 


Symptoms  of  Thoracic  Aneurism. 

The  symptoms  of  thoracic  aneurism  are  mainly  due  to  pressure 
of  the  aneurismal  tumor  on  the  surrounding  parts.     If  the  tumor 


444  THOKACIC    ANEURISMS. 

be  small,  and  so  situated  as  not  to  contract  adhesions  with,  and 
press  upon,  certain  portions  of  the  intra-thoracic  organs,  it  may 
remain  latent  for  an  indefinite  period.  Rupture  and  sudden  death 
occur  not  very  infrequently,  when  there  had  been  no  symptoms 
to  excite  suspicion  of  the  existence  of  aneurism.  Aneurismal 
tumors,  however,  frequently  give  rise  to  symptoms  more  or  less 
marked  and  characteristic,  which  are  referable  to  the  respiratory 
system  and  voice,  the  function  of  deglutition,  the  venous  circula- 
tion, and  the  arterial  pulse. 

If  the  tumor  press  on  the  trachea,  or  a  bronchus,  so  as  to  diminish 
considerably  the  calibre  of  one  or  both  of  these  tubes,  or  encroach 
largely  on  the  space  which  the  lungs  should  occupy,  embarrassment 
of  respiration  may  occur,  manifested  especially  when  an  unusual 
demand  is  made  on  the  respiratory  function,  as  in  active  muscular 
exercise.  The  enlargement  of  the  tumor,  however,  being  gradual, 
the  diminished  calibre  of  the  tubes,  or  the  displacement  of  the 
lung-substance,  although  considerable,  does  not  uniformly  occasion 
notable  want  of  breath  even  on  exercise.  But  in  some  cases  dysp- 
noea is  a  very  prominent  symptom.  In  an  instance  which  came 
under  my  observation,  in  which  the  aneurism  was  of  large  size,  and 
seated  at  the  arch,  the  patient  suffered  extremely  and  constantly 
from  labored  breathing,  being  unable  to  lie  down  for  weeks  before 
death.  The  most  comfortable  position  was  leaning  far  forward, 
with  the  arms  resting  on  the  knees ;  raising  the  body  to  the  erect 
posture  increased,  in  a  marked  degree,  the  dyspncea.  In  this  case, 
no  difficulty  of  breathing  was  experienced,  and  the  patient  was  able 
to  perform  hard  manual  labor  up  to  the  time  when  an  external 
tumor  became  visible.  Dyspnoea,  however,  proceeds  from  so  many 
and  various  morbid  conditions,  that,  alone,  it  is  in  nowise  distinctive 
of  aneurism.  Its  significance  is  derived  from  concomitant  signs 
showing  the  existence  of  an  intra-thoracic  tumor  which  is  probably 
aneurismal.  This  remark  is  also  applicable  to  cough,  which  in 
some  cases  of  aneurism  is  a  prominent  symptom,  being  either  dry 
and  spasmodic,  or  accompanied  by  more  or  less  mucous,  and  occa- 
sionally bloody,  expectoration ;  while  in  other  cases  it  is  sliglit,  and 
may  be  wanting.  Aneurisms  seated  at  the  arch  are  most  apt  to  be 
attended  by  symptoms  referable  to  the  respiratory  system.  The 
dyspnoea  and  cough  are,  in  general,  effects  of  mechanical  com- 
pression of  the  air-tubes  and  pulmonary  organs ;  but  irritation  or 
stretching  of  the  par  vagum  and  phrenic  nerve  on  the  left  side  may 
contribute  to  the  development  or  prominence  of  these  symptoms. 


SYMPTOMS    OF    THORACIC    AISTEURISMS,  445 

and  sometimes  give  rise  to  them  independently  of  pressure  of  the 
tumor  on  the  trachea,  bronchi,  or  lungs.  Dyspnoea  and  cough, 
when  produced  mechanically,  are  generally  attended  by  wheezing 
or  stridulous  breathing,  which  may  be  audible  at  a  distance  from 
the  patient.  This  will  be  noticed  presently,  in  connection  with  the 
physical  signs  of  aneurism. 

Impairment  of  the  voice,  and  aphonia,  are  symptoms  which  in 
some  cases  are  highly  significant.  These  symptoms  are  developed 
when  the  tumor  involves  the  recurrent  nerve  so  as  to  interrupt  its 
functions.  This  is  apt  to  occur  if  the  aneurism  spring  from  the 
left  side  of  the  transverse  portion  of  the  arch.  Dependent  on  the 
situation  of  the  tumor  being  such  as  to  occasion  pressure,  with  irri- 
tation, of  the  recurrent  nerve,  these  symptoms  characterize  in  a 
striking  manner  certain  cases,  while  in  other  cases  the  voice  re- 
mains unaltered,  notwithstanding  dyspnoea,  cough,  and  stridulous 
breathing  may  be  present.  Hoarseness,  feebleness,  or  extinction  of 
the  voice,  if  aneurism  be  not  suspected,  may  lead  the  practitioner 
to  infer  the  existence  of  laryngitis.  The  coexistence  of  the  pulmo- 
nary symptoms  just  mentioned  may  appear  to  sustain  this  inference. 
Tracheotomy  has  been  repeatedly  performed  under  these  circum- 
stances. In  fact,  inflammation  of  the  laryngeal  mucous  membrane 
and  oedema  of  the  glottis  are  sometimes  produced  by  pressure  of 
the  aneurismal  tumor;  but  the  alteration  and  loss  of  voice  may  be 
entirely  functional.  Dr.  Stokes  has  indicated  a  point  of  distinction 
between  functional  affection  of  the  voice  arising  from  pressure  on 
the  recurent  nerve,  and  the  alteration  dependent  on  laryngeal  dis- 
ease, viz.,  in  the  latter  the  hoarseness  or  aphonia  is  constant,  and 
in  many  cases  the  voice  is  never  restored,  while  in  the  former  re- 
markable variations  in  the  tone  and  power  of  the  voice  frequently 
occur  within  short  spaces  of  time.  In  a  case  of  aneurism  of  the 
innominata,  in  which  the  recurrent  nerve  was  found  stretched  over 
the  tumor  like  a  broad  ribbon,  the  variations  of  voice  were  truly 
remarkable.  "  Within  twenty-four  hours  it  would  change  from 
the  highest  treble  to  a  deep  bass;  at  one  time  it  was  an  inaudible 
whisper,  at  another  hoarse  and  croaking;  and  this  variability  con- 
tinued up  to  the  period  of  death."'  The  hoarseness  or  aphonia  due 
to  aneurism  may  disappear  for  a  time,  and  again  return.  This 
occurred  in  a  case  which  came  under  my  observation.  In  the  case 
now  referred  to,  the  alteration  of  the  voice  was  the  first  symptom 

'  Op.  cit.,  p.  585. 


446  THORACIC    ANEURISMS. 

which  indicated  the  existence  of  any  disease.  The  patient  supposed 
that  he  had  taken  cold,  and  came  to  the  hospital  to  be  treated  for 
an  affection  of  the  air-passages.  Up  to  that  time  he  felt  no  incon- 
venience in  performing  active  manual  labor.  Bulging  at  the  top 
of  the  sternum,  and  abundant  evidence  of  an  aneurismal  tumor 
pressing  on  the  left  bronchus  and  suppressing  respiration  in  the 
right  lung,  were  apparent  on  an  examination  made  some  weeks 
afterwards. 

Pressure  of  the  tumor  on  the  oesophagus  interferes  with  the 
function  of  deglutition,  giving  rise  to  dysphagia  from  obstruction. 
This  is  liable  to  occur  when  the  site  of  the  aneurism  is  at  the  trans- 
verse or  descending  aorta.  It  is,  however,  less  frequent  than  the 
sj^mptoms  referable  to  the  respiratory  system.  It  may  coexist  with 
the  latter,  but  is  sometimes  present  without  them.  It  may  be  the 
only  prominent  symptom,  and,  if  aneurism  be  not  suspected,  stric- 
ture of  the  oesophagus  will  then  be  likely  to  be  inferred. 

As  a  judicious  precaution,  an  examination  should  be  made  for 
the  signs  of  aneurism  in  cases  of  dysphagia  dependent  on  obstruc- 
tion seated  below  the  pharynx,  before  resorting  to  the  use  of  the 
probang,  since  rupture  of  the  aneurismal  sac  has  been  produced  by 
the  passage  of  this  instrument.  The  difficulty  of  deglutition  varies, 
of  course,  according  to  the  amount  of  obstruction  ;  it  may  be  slight, 
or  the  ingestion  of  solid  food  may  be  impossible,  so  that  the  body 
suffers  from  inanition.  When  the  obstruction  is  extreme,  the 
attempt  to  swallow,  especially  solids,  frequently  provokes  parox- 
ysms of  pain  and  spasm,  together  with  cough  and  dyspnoea,  fol- 
lowed by  regurgitation  of  the  food  arrested  in  its  progress  down 
the  oesophagus.  The  patient  refers  the  seat  of  the  difficulty  to  the 
top  or  middle  of  the  sternum,  and  sometimes  to  the  epigastrium. 
Dr.  Stokes  cites  a  case  reported  by  Dr.  Law,  in  which  the  patient 
could  not  swallow  in  the  recumbent  position,  but  always  took  his 
food  while  sitting  up,  with  the  body  bent  forward  and  to  one  side. 
The  explanation  of  this  is  sufficiently  obvious.  The  dysphagia 
has  been  observed  to  diminish  and  even  disappear  as  the  aneurism 
increased  in  size,  a  fact  to  be  accounted  for  by  supposing  that  with 
the  lateral  extension  of  the  tumor,  the  direct  pressure  on  the  oeso- 
phagus was  lessened.^  The  degree  of  difficulty  may  be  pretty 
uniform,  or  it  may  vary  much  at  different  times,  owing  to  varia- 
tions in  the  amount  of  distension  of  the  aneurismal  sac,  or  to  the 
development  of  spasmodic  action  in  addition  to  the  pressure. 

'  Bellingliam,  oj).  cit.,  p.  594. 


SYMPTOMS    OF    THORACIC    ANEUEISMS.  447 

Pressure  on  the  superior  vena  cava,  or  the  venge  innominatse, 
gives  rise  to  venous  congestion  of  the  face,  neck,  and  upper  ex- 
tremities. The  veins  of  the  neck  on  one  or  both  sides  are  fre- 
quently distended  and  tortuous,  giving  rise,  in  some  instances,  to  a 
varicose  appearance.  The  face  may  be  congested  to  such  an  extent 
that  it  presents  a  deeply  livid  and  swollen  aspect.  The  neck  is 
sometimes  pufled  out  by  vascular  turgescence  and  oedema,  forming 
what  Dr.  Stokes  calls  a  "tippet-like  swelling."  The  distension  of 
the  veins,  the  lividity  and  oedema,  may  extend  to  one  or  both  of 
the  upper  extremities.  Venous  congestion  and  oedema  thus  limited, 
point  to  obstruction  seated,  not  at  the  centre  of  the  circulation,  but 
in  the  venous  trunks  which  have  been  mentioned.  These  veins  are 
likely  to  become  involved  in  aneurisms  springing  from  the  ascend- 
ing and  transverse  aorta.  Absence  of  jugular  pulsation  is  a  point 
distinguishing  the  congestion  due  to  obstruction  seated  above  the 
heart,  from  that  arising  from  cardiac  lesions  which  involve  tricuspid 
regurgitation.  Physical  exploration,  perhaps,  shows  that,  in  con- 
nection with  notable  congestion  apparent  only  above  the  heart, 
cardiac  disease  is  either  slight  or  wanting,  and  thus  affords  addi- 
tional evidence  of  the  seat  of  the  obstruction.  Under  these  circum- 
stances, the  existence  of  an  aneurismal  or  other  intra-thoracic  tumor 
pressing  on  the  veins  which  return  the  blood  from  the  head  and 
upper  extremities,  is  almost  certain.  Yenous  congestion,  as  just 
described,  is  by  no  means  present  in  all  cases  of  aneurism.  Like 
the  other  symptoms,  its  absence  is  not  proof  that  aneurism  does 
not  exist ;  but  when  marked  in  the  upper  portion  of  the  body  and 
wanting  below,  in  conjunction  with  other  symptoms,  and  with 
signs  pointing  to  aneurism,  it  is  highly  significant. 

Inequality  in  the  pulse  at  the  wrists,  and  the  loss  of  the  pulse  on 
one  side,  are  effects  of  the  obstruction  of  the  arteria  innominata  or 
the  left  subclavian  incident  to  certain  cases  of  aneurism.  These 
effects  become  important  symptoms  taken  in  connection  with  other 
symptomatic  phenomena.  The  pulse  on  the  left  oftener  than  on 
the  right  side  is  weakened  or  suppressed,  the  left  subclavian  from 
its  situation  being  the  most  exposed  to  pressure.  In  comparing 
the  pulse  on  the  two  sides,  it  is  to  be  borne  in  mind  that  it  is 
normally  somewhat  more  developed  in  the  right  than  in  the  left 
arm ;  relative  weakness  on  the  right  side  is  therefore  more  signifi- 
cant of  disease.  The  carotid  as  well  as  the  subclavian  artery  on 
one  side  may  be  obstructed,  so  that  pulsation  in  this  artery  and  its 
branches  is  relatively  feeble  or  extinct.     These  effects  on  the  arte- 


448  THORACIC    ANEURISMS. 

rial  pulse,  in  general,  denote  that  the  aneurismal  tumor  springs 
from  the  arch  of  the  aorta.  Owing  to  a  change  in  the  direction  of 
the  tumor,  arterial  pulsation,  which  had  been  at  one  time  sup- 
pressed in  the  neck  or  wrist,  may  be  subsequently  restored ;  and, 
for  the  same  reason,  having  been  weakened,  it  may  become 
stronger.  In  these  instances,  the  weakness  and  suppression  were 
due  to  the  outward  pressure  of  the  aneurismal  tumor  on  the  sub- 
clavian, carotid,  or  innominata;  but  in  the  instances  in  which  these 
arterial  trunks  are  obstructed  from  within  by  fibrinous  deposit,  the 
deficiency  or  absence  of  pulsation  is  likely  to  remain  unaltered. 

The  symptoms  which  have  been  noticed  are  important  in  aiding 
to  determine  the  existence  of  an  aneurism  and  its  probable  seat. 
These  symptoms  may  be  present,  individually  or  collectively,  in 
different  cases ;  each  may  exist  without  the  others,  and  all  may  be 
wanting.  Singly  or  combined,  they  are  not  pathognomonic  of 
aneurism.  Being  mostly  the  immediate  effects  of  eccentric  pres- 
sure, they  may  be  alike  produced  by  any  intra-thoracic  tumor. 
Hence,  their  diagnostic  value  depends  on  other  evidence  of  the 
existence  of  aneurism  being  conjoined,  especially  that  furnished  by 
physical  signs,  to  be  presently  considered.  Other  symptoms  less 
characteristic  and  consisting  of  secondary  or  remote  effects  remain 
to  be  briefly  noticed. 

More  or  less  pain  usually  attends  the  progress  of  thoracic  aneu- 
risms. Pain,  however,  is  less  constant  and  less  marked  as  a  symp- 
tom in  aneurisms  seated  within  the  chest  than  within  the  abdomen. 
Aneurism  of  the  abdominal  aorta  frequently  gives  rise  to  intense, 
persisting  pain,  while  this  is  true  of  only  a  small  proportion  of 
cases  of  aneurism  afl'ecting  the  thoracic  aorta.  Of  thoracic  aneu- 
risms, those  springing  from  the  descending  aorta  are  far  more  apt 
to  give  rise  to  pain  than  those  seated  in  the  ascending  aorta  or  at 
the  arch.  The  pain  is  especially  marked  if  the  aneurismal  sac 
cause  erosion  of  the  bodies  of  the  vertebrae.  In  these  cases, 
patients  describe  the  pain  as  boring  or  gnawing  in  character,  and  it 
is  sometimes  referred  to  a  small  circumscribed  portion  of  the 
vertebral  column.  Aneurisms  seated  in  the  ascending  or  trans- 
verse aorta  are  often  unattended  by  severe  pain,  but  in  some  cases 
it  is  a  prominent  symptom.  In  these  cases,  it  is  generally  inter- 
mittent, and  resembles  that  of  a  neuralgic  affection,  being  lanci- 
nating in  character,  shifting  its  situation,  and  shooting  in  various 
directions.  In  other  cases,  an  obtuse,  persisting  pain  is  complained 
of.     The  pain  may  be  referred  to  difi'erent  portions  of  the  chest, 


SYMPTOMS    OF    THORACIC    ANEURISMS.  449 

extending  not  infrequently  to  the  shoulders,  neck,  and  arms. 
Occasionally,  it  bears  some  resemblance  to  the  pain  of  angina 
pectoris.  When  an  external  tumor  makes  its  appearance,  the  pain 
may  be  referred  to  the  part  where  it  appears ;  and  prior  to  this 
event,  pain  in  some  cases  is  not  present.  The  parts  over  an 
aneurismal  tumor  are  often  tender,  rendering  pressure  and  percus- 
sion painful. 

Paraplegia  becomes  a  symptom  of  aneurism,  if,  when  seated  in 
the  descending  aorta,  it  leads  to  erosion  of  the  vertebras,  and  the 
pressure  of  the  tumor  falls  upon  the  spinal  cord. 

Hemiplegia  may  occur  as  a  remote  effect.  Clinical  observation 
shows  its  occurrence  in  a  certain  proportion  of  cases;  but  it  may 
be  dependent  on  disease  of  the  cerebral  arteries,  analogous  to  that 
which,  in  the  aorta,  preceded  the  formation  of  aneurism.  Under 
these  circumstances,  its  occurrence  may  be  merely  due  to  coinci- 
dence. Exclusive  of  these  instances,  it  is  probably  sometimes  due 
to  fibrinous  coagula  detached  from  within  the  aneurismal  sac  and 
arrested  in  the  arteries  of  the  brain.  Dr.  Stokes  attributes  this  and 
other  symptoms  referable  to  the  brain,  to  diminished  supply  of 
blood,  in  the  cases  in  which  the  carotid  artery  on  one  side  is 
obstructed.  More  importance  probably  belongs  to  the  cerebral  con- 
gestion incident,  in  certain  cases,  to  pressure  on  the  vena  cava.  In 
connection  with  the  appearances  denoting  interruption  of  the  return 
of  blood  to  the  heart,  drowsiness,  dulncss  of  the  intellect,  obtuse 
pain  in  the  head,  and  other  signs  denoting  passive  congestion  of 
the  brain,  are  usually  present;  and  in  one  case  under  my  observa- 
tion, paralysis  of  the  muscles  of  the  face  on  one  side  existed.  It  is 
intelligible  that  the  vascular  fulness  in  these  cases  should  favor  the 
occurrence  of  extravasation  giving  rise  to  apoplexy  and  hemiplegia. 

The  existence  of  aneurism  does  not  involve,  directly  and  speedily, 
any  notable  change  in  the  general  aspect  of  the  patient.  Eokitan- 
sky  states  that  if  the  aneurismal  sac  attain  to  a  large  size,  sufficient 
blood  may  be  withdrawn  from  the  circulation  to  induce  anasmia. 
Patients  sometimes  preserve  their  weight  and  strength  to  the  last, 
but  in  other  cases  both  undergo  more  or  less  diminution.  From 
an  analysis  of  seventeen  cases  of  aneurism  seated  at  the  arch.  Dr. 
Walshe  is  led  to  the  conclusion  that  the  difference  in  different  cases 
as  regards  loss  of  weight  and  strength,  is  mainly  owing  to  the  pre- 
sence or  absence  of  severe  pain.  In  proportion  as  this  element  is 
prominent,  patients  emaciate  and  become  enfeebled.  Extreme 
29 


450  THORACIC    ANEURISMS. 

emaciation  is  sometimes  produced  by  pressure  of  the  aneurismal 
tumor  on  the  thoracic  duct. 

Dr.  Gairdner,  of  Edinburgh,  and  Dr.  Banks,  of  Dublin,  have 
recently  called  attention  to  the  occurrence  of  contraction  of  the 
pupil  of  the  eye,  on  the  side  of  the  aneurism,  when  the  tumor  ex- 
tends high  up  in  the  neck.  This  effect  is  attributed  to  pressure 
upon  the  sympathetic  nerve  in  the  neck,  division  of  this  nerve  on 
one  side  having  been  found  in  experiments  on  living  animals  to  be 
followed  by  contraction  of  the  pupil  of  that  side.' 

Gangrene  of  the  lung  is  a  rare  symptomatic  event,  which,  accord- 
ing to  Dr.  Carswell,  is  induced  by  compression  of  the  nutrient 
arteries  of  the  lung  by  the  aneurismal  tumor.^ 


Physical  Signs  of  Thoracic  Aneurism. 

The  physical  signs  of  thoracic  aneurism  are  furnished  by  Inspec- 
tion, Palpation,  Percussion,  and  Auscultation.  I  shall  consider  the 
phenomena  obtained  by  these  methods,  severally,  following  the 
order  in  which  they  are  enumerated. 

Inspection  is  frequently  not  available  until  the  aneurismal  sac 
presses  upon  the  parietes  of  the  chest  at  some  point  and  gives  rise 
to  visible  bulging  of  the  surface.  The  presence  of  an  external 
swelling  or  tumor  is  determined  by  the  eye.  At  first  slight,  and 
limited  to  a  circumscribed  area,  the  swelling  may  increase  so  as  to 
form  a  tumor  as  large  as  the  foetal  head.  The  form  is  usually 
conical,  and  the  surface,  if  the  tumor  be  of  considerable  size,  is 
smooth,  and  frequently  presents  a  glazed  appearance.  Pulsatory 
movements  at  the  site  of  the  bulging,  or  tumor,  may  or  may  not  be 
apparent  on  inspection.  A  pulsation  may  be  seen  when  bulging 
has  not  occurred.  The  appearance  is  then,  as  remarked  by  Dr. 
Stokes,  as  if  two  hearts  were  beating  in  the  chest  in  different  situa- 
tions. This  pulsation  without  swelling  may  sometimes  be  dis- 
covered by  looking  across  the  surface  with  the  eye  brought  down 
to  a  level  of  the  chest,  when  it  is  not  apparent,  if  the  ordinary 
mode  of  inspection  be  alone  employed.  This  is  a  practical  point 
to  be  borne  in  mind. 

Palpation  enables  the  observer  to  ascertain  the  form  of  the  swell- 

'  Bellingham,  op.  cit.,  page  609. 
*  Stokes,  op.  cit.,  page  587. 


SIGNS    OBTAINED    BY    PALPATION.  451 

ing,  the  condition  of  the  surface  as  regards  smoothness,  and  the 
amount  of  resistance  to  pressure.  By  manipulations  with  the  hand, 
also,  perforation  of  the  thoracic  walls  may  be  ascertained ;  the 
edges  of  the  eroded  ribs  or  sternum  at  the  aperture  through  which 
the  aneurismal  sac  protrudes,  may  be  felt.  Fluidity  of  the  contents 
of  the  tumor  is  sometimes  apparent  to  the  touch.  The  liquid 
contents  of  the  sac  may  be  diminished  by  manual  pressure,  and 
reduction  of  the  hernia-like  protrusion  perhaps  effected.  Much 
compression  of  the  tumor,  however,  is  not  to  be  advised,  since  there 
may  be  risk  of  producing  rupture,  or  of  detaching  coagulated  fibrin 
from  within  the  sac,  and  thus  giving  rise  to  emboli,  as  well  as 
weakening  the  aneurismal  walls. 

Palpation  is  especially  useful  in  determining  the  presence  and 
character  of  pulsatory  movements.  Assuming  that  bulging  exists, 
pulsation  constitutes  important  evidence  of  its  being  aneurismal. 
As  a  rule,  an  external  aneurismal  tumor  is  pulsatile;  but  to  this 
rule  there  are  exceptions.  If  the  sac  be  nearly  or  quite  filled  with 
solid  fibrin,  the  stream  of  blood  through  the  artery  small,  and  the 
heart's  action  weak,  an  impulse,  visible  or  tactile,  may  be  wanting. 
On  the  other  hand,  intra-thoracic  tumors  not  aneurismal,  often 
present  distinct  and  strong  pulsation.  The  impulse  varies  greatly 
in  strength  in  different  cases,  being  sometimes  extremely  powerful, 
raising  with  force  the  head  applied  for  auscultation,  and  accom- 
panied by  a  shock  which  agitates  the  whole  body,  and  of  which  the 
patient  is  painfully  conscious  ;  in  other  cases  it  is  scarcely  percep- 
tible, and  between  these  extremes  every  degree  of  gradation  may 
be  observed.  The  character  of  the  aneurismal  impulse,  when 
strong,  as  Dr.  Stokes  justly  remarks,  differs  from  that  of  the  heart's 
beat  in  the  state  of  health  or  of  active  hypertrophy.  The  difference 
arises  from  the  fact  that  in  aneurism  the  impulse  is  due  to  the 
momentum  communicated  to  a  column  of  liquid,  while  the  beat  of 
the  heart  is  owing  to  the  pressure  of  the  apex  of  the  organ  against 
the  chest  in  its  elongating  and  rotating  movements.  Quoting  the 
language  of  the  author  just  named:  "  The  aneurismal  beat  generally 
gives  the  idea  of  a  forcible  blow,  having  a  force  equal  in  all  direc- 
tions, while  that  of  the  heart  conveys  the  sensation  of  a  mobile  but 
solid  body,  which,  in  many  instances  at  least,  presents  its  greatest 
force  at  a  particular  point,"^  This  character  of  impulse,  and  its 
strength,  are  proportionate  to  the  proximity  of  the  sac  to  the  in- 

'  Op.  cit.,  p.  554. 


452  THORACIC    ANEURISMS. 

tegument;  the  deficiency  of  solid  fibrin,  or,  in  other  words,  the 
relative  amount  of  liquid  blood  within  the  aneurismal  cavity;  the 
freedom  of  communication  between  the  aneurismal  cavity  and  the 
artery,  and  the  power  of  the  heart's  action.  The  impulse  may  be 
single  or  double.  When  single,  it  is  synchronous  with  the  ven- 
tricular systole,  being  due  directly  to  the  contraction  of  the  left 
ventricle.  If  double,  the  second  impulse  must  be  produced  by  the 
recoil  of  the  arterial  coats  following  distension  of  the  artery  by  the 
onward  current  of  blood  ;  it  is  thus  indirectly  due  to  the  contraction 
of  the  left  ventricle,  and  coincides  in  time  with  the  second  sound 
of  the  heart,  or,  in  other  words,  it  is  diastolic.  A  double  pulsation, 
therefore,  consists  of  a  systolic  and  a  diastolic  impulse. 

In  these  remarks  it  is  assumed  that  the  aneurismal  sac  has  led 
to  bulging  or  an  external  tumor.  But,  impulse  may  be  perceived 
by  the  touch,  as  well  as  by  the  eye,  before  bulging  is  apparent. 
A  throbbing,  synchronous,  or  nearly  so,  with  the  systole  of  the 
heart,  may  be  felt,  over  a  circumscribed  space,  at  a  point  more  or 
less  removed  from  the  seat  of  the  apex-beat.  There  appear  to  be 
two  hearts  beating  within  the  chest.  The  presence  of  the  apex- 
beat  at  or  near  its  normal  situation,  is  evidence  that  the  abnormal 
pulsation  is  not  of  the  heart  itself;  and  that  it  is  not  the  apex-beat 
propagated  at  a  distance  from  the  apex,  is  shown  by  its  being  felt 
within  a  circumscribed  space,  and  not  felt  between  this  space  and 
the  point  where  the  apex  comes  into  contact  with  the  parietes  of 
the  chest.  A  source  of  fallacy  connected  with  the  heart  may  be 
here  mentioned.  Free  regurgitation  through  the  tricuspid  orifice 
with  dilatation  of  the  right  auricle  and  hypertrophy  of  the  right 
ventricle,  may  occasion  a  strong  pulsation  on  the  right  side  of  the 
sternum.  An  instance  related  by  Dr.  Stokes  has  been  referred  to 
in  a  former  part  of  this  work."  Aneurismal  pulsation  without 
bulging,  varies  in  diflerent  cases  from  an  intensity  exceeding  con- 
siderably that  of  the  heart's  beat,  to  a  feebleness  so  great  that  it  is 
almost  imperceptible.  The  throbbing  may  sometimes  be  perceived 
in  some  cases  by  placing  one  hand  on  the  posterior  part  of  the 
chest,  and  making  firm  pressure  with  the  other  hand  over  the 
upper  part  of  the  sternum,  when,  Avith  a  manual  examination  by 
one  hand  alone,  it  is  not  appreciable.  The  pulsation  is  most  evi- 
dent or  marked  at  the  end  of  an  expiratory  act.  If  the  aneurism 
be  seated  at  the  arch  and  extend  upv/ards,  a  pulsation  may  be  felt 

'   Vide  p.  54. 


I 


SIGNS    OBTAINED    BY    PERCUSSION.  453 

at  an  early  period,  before  bulging  occurs,  by  passing  the  finger  into 
the  sternal  notch,  and  pressing  downward  towards  the  artery.  The 
aneurisraal  tumor  may  sometimes  be  felt  in  this  way,  before  any 
visible  swelling  occurs. 

Tactile  fremitus,  or  thrill,  with  the  heart's  systole,  felt  over  an 
aneurismal  tumor,  is  a  physical  sign  which  in  some  cases  is  strongly 
marked,  but  it  is  by  no  means  uniformly  present.  It  may  be  pre- 
sent when  the  impulse  is  slight  or  wanting.  It  is  sometimes  present 
in  cases  of  intra-thoracic  tumor,  not  aneurismal.  While  its  absence 
is  not  proof  that  a  tumor  is  not  aneurismal,  and  when  present,  it 
does  not  constitute  positive  evidence  of  aneurism,  it  has,  neverthe- 
less, in  conjunction  with  other  signs,  considerable  value,  especially 
if  it  exist  in  a  notable  degree. 

Percussion  is  useful  in  certain  cases  by  aiding  to  determine  the 
existence  of  a  tumor,  and  affords  evidence  of  its  size.  If  an  external 
tumor  have  formed,  its  size,  as  determined  by  the  eye  and  touch, 
is  no  criterion  of  the  size  of  the  aneurismal  sac ;  the  latter  extends 
over  an  area,  greater  or  less,  without  the  limits  of  the  visible  tumor. 
Its  extent  may  sometimes  be  ascertained  with  considerable  accuracy 
by  means  of  percussion,  provided  the  pressure  on  the  lung-substance 
has  not  induced  induration,  in  which  case  the  percussion-dulness 
will  extend  farther  than  the  walls  of  the  sac.  It  is  to  be  borne  in 
mind  that  the  lung  may  cover  a  portion  of  the  aneurisraal  sac,  so 
that  the  limits  of  the  latter  are  not  defined  by  absence  of  pulmonary 
resonance.  An  aneurismal  sac,  in  fact,  like  the  heart,  has  its  area 
of  superficial,  and  its  area  of  deep  dulness  on  percussion.  The 
former  marks  the  space  over  which  the  sac  is  uncovered  of  lung ; 
and  the  latter  the  distance  to  which  the  sac  extends  beneath  the 
lung.  The  situation  of  the  dulness  goes  to  show  the  probable 
origin  of  the  tumor.  Well  defined  abnormal  dulness  over  the  site 
of  the  ascending  and  transverse  aorta,  in  connection  with  other 
signs  and  with  symptoms,  points  to  the  existence  of  aneurism.  An 
aneurismal  tumor  of  small  size  in  the  situations  just  named,  if  not 
arising  from  the  posterior  margin  of  the  vessel,  may  occasion  an 
abnormal  degree  and  extent  of  dulness  determinable  by  careful 
percussion.  Dr.  Walshe  states  that  "  a  sac  as  large  as  a  good-sized 
walnut  may  be  discovered,  if  it  lie  anywhere  between  the  second 
right  interspace  and  the  left  border  of  the  sternum,  and  there  be  no 
special  and  unusual  source  of  difficulty  in  the  way."  Percussion  is 
less  available  if  the  aneurismal  sac  spring  from  the  descending 
aorta.     When  the  sac  attains  to  a  certain  size,  however,  it  gives 


454  THORACIC    ANEURISMS. 

rise  to  dulness  sufTiciently  defined  behind  ia  the  interscapular 
space.  It  is  obvious  that  percussion,  alone,  can  only  furnish 
evidence  that  abnormal  dulness  from  some  cause  exists ;  that  this 
dulness  depends  on  an  aneurism,  and  not  on  an  intra-thoracic 
tumor,  not  aneurismal,  or  other  causes,  is  to  be  determined  by 
other  signs  and  by  symptoms. 

The  signs  furnished  by  auscultation  are  referable  not  alone  to  the 
aneurismal  sac,  or  the  artery  with  which  it  communicates,  but  to 
the  trachea,  bronchi,  and  pulmonary  organs.  Directing  attention 
first  to  the  signs  proceeding  directly  from  the  aneurism,  it  gives 
rise,  in  a  certain  proportion  of  cases,  to  a  bellows  murmur.  This 
sign  is  by  no  means  constant ;  it  is  frequently  wanting.  Dr.  Stokes, 
indeed,  regards  it  as  an  accidental  phenomenon  so  commonly  want- 
ing that  he  considers  its  occurrence  as  exceptional.  Its  infrequency 
is  exaggerated  in  this  statement;  but,  owing  to  its  being  so  often 
absent,  it  has  far  less  value,  as  a  sign  of  thoracic  aneurism,  than 
has  been  generally  supposed.  As  an  isolated  sign,  it  possesses 
very  small  value  for  other  reasons  than  its  want  of  constancy. 
Aortic  murmurs  are  sufficiently  common,  exclusive  of  aneurism. 
It  has  been  already  seen  that  they  are  often  generated  by  the 
passage  of  the  blood-current  over  the  internal  surface  of  the  vessel, 
when  roughened  by  atheromatous  and  calcareous  disease,  without 
dilatation.  Alone,  therefore,  a  bellows  murmur  referable  to  the 
aorta  is  not  proof  of  the  existence  of  aneurism.  Other  signs  and 
symptoms  must  be  conjoined  to  render  it  significant  of  this  affec- 
tion. It  can  hardly  be  said  to  contribute  evidence  of  aneurism 
unless  the  existence  of  a  tumor  be  determinable,  and  even  then  it 
is  not  distinctive,  since  an  intra-thoracic  tumor,  not  aneurismal,  by 
pressure  on  the  aorta,  may  give  rise  to  murmur.  The  passage  of 
blood  within  and  without  an  aneurismal  sac  does,  however,  give 
rise  to  murmur  in  a  certain  proportion  of  cases.  This  murmur 
varies  in  intensity  from  the  faintest  pufl'  to  a  loudness  exceeding 
that  of  the  most  intense  cardiac  murmurs.  It  may  be  soft  or 
rough.  It  is  sometimes  most  marked  over  the  most  prominent 
portion  of  the  aneurismal  tumor,  and  in  other  instances  it  is  heard 
loudest  at  the  base  of  the  tumor.  It  is  said  to  be,  as  a  rule,  less 
prolonged  than  valvular  murmurs  and  lower  in  pitch.  Aneurismal 
murmur  may  be  single  or  double.  If  single,  it  is  usually,  but  not 
invariably,  systolic,  i.  e.,  synchronous  with  the  ventricular  systole. 
The  second  murmur  is  sjmchronous  with  the  second  sound  of  the 
heart,  and  may,  therefore,  be  distinguished  as  diastolic.     The  latter 


SIGNS    OBTAINED    BY    AUSCULTATION.  455 

is  rarely,  if  ever,  rough,  and  is  less  intense  than  the  systolic  murmur. 
An  aneurismal  murmur  is  to  be  discriminated  from  cardiac  and 
arterial  murmurs.  A  murmur  emanating  from  the  heart  may  be 
propagated  to  the  aneurism.  A  propagated  cardiac  murmur  may 
perhaps  be  more  intense  over  the  aneurism,  if  the  tumor  be  near 
the  surface,  than  at  any  point  between  the  aneurism  and  its  source; 
but  its  maximum  of  intensity  will  be  at  or  just  above  the  base  of 
the  heart.  If  more  intense  over  the  aneurism  than  at  or  near  the 
base  of  the  heart,  it  may  be  considered  as  not  cardiac  in  its  origin. 
But,  in  most  cases,  if  a  cardiac  murmur  coexist  with  an  aneurismal, 
comparison  of  the  two  murmurs  will  show  differences  as  regards 
quality  and  pitch,  sufficient  to  denote  that  they  are  distinct  from 
each  other.  A  murmur  propagated  from  the  heart  must  be  pro- 
duced at  the  aortic  orifice.  A  mitral  murmur  is  not  conducted 
along  the  aorta;  hence,  when  a  coexisting  cardiac  murmur  is  ascer- 
tained to  be  mitral,  its  identity  with  a  murmur  heard  over  an 
aneurismal  tumor  is  not  a  matter  of  question.  Murmur  emanating 
from  the  artery,  elsewhere  than  at  its  point  of  communication  with 
the  aneurism,  may  be  due  to  disease  of  the  arterial  coats,  or  it  may 
be  inorganic,  i.  e.,  dependent  on  blood-changes.  If  due  to  the 
former,  the  maximum  of  intensity  of  the  murmur  will  not  be  likely 
to  be  at  the  aneurismal  tumor;  if  to  the  latter,  the  murmur  will 
generally  be  diff"used  over  the  vessels  of  the  neck  and  attended  by 
venous  hum.  An  ansemic  condition  doubtless  favors  the  produc- 
tion of  an  aneurismal  murmur  and  enhances  its  intensity.  Finally, 
an  aneurismal  murmur  is  found  to  vary  at  different  periods,  and 
even  from  day  to  day ;  and  it  may  exist  for  a  certain  period  with 
marked  intensity,  so  as  even  to  be  appreciable  without  auscultation, 
and  subsequently  disappear.^ 

Aneurismal  sounds,  as  well  as  cardiac,  are  to  be  distinguished 
from  murmurs.  A  double  sound,  corresponding  to  the  systolic  and 
diastolic  sound  of  the  heart,  is  usually  heard  on  auscultation  of 
an  aneurismal  tumor  springing  from  the  aorta.  The  two  sounds 
resemble  those  of  the  heart,  not  only  in  rhythm,  but  in  other 
characters.  Dr.  Stokes  remarks:  "They  are  so  similar  to  those  of 
the  heart,  that,  were  a  good  observer  blindfolded,  and  the  stetho- 
scope placed  for  him  over  the  seat  of  the  disease,  he  would  find  it 
difficult,  if  not  impossible,  to  distinguish  them  from  the  ordinary 
sounds  of  an  excited  heart."     I  believe  them  to  be  neither  more 

'  Walshe,  op.  cit.,  page  749. 


45G  THOEACIC    ANEURISMS. 

nor  less  than  the  heart-sounds  transmitted  by  the  walls  of  the  ar- 
tery and  the  current  of  blood,  to  the  aneurismal  sac.  lEolding  this 
belief,  I  do  not  deem  it  necessary  to  discuss  the  modes  in  which  the 
sounds  have  been  supposed  to  be  produced  within  the  sac.  That 
they  should  be  propagated  so  as  to  be  heard  with  more  intensity 
over  the  aneurism  than  at  any  point  between  it  and  the  heart,  is 
readily  conceivable  in  view  of  the  nearness  to  the  ear  of  the  arterial 
walls  and  current  of  blood,  when  the  aneurismal  tumor  is  auscul- 
tated. The  systolic  sound  appears  to  be  sometimes  reinforced  by 
an  element  of  impulsion  derived  from  the  shock  communicated  to 
the  sac  by  the  onward  current  of  blood  ;  and  this  element  of  impul- 
sion is  sometimes  the  only  sound  appreciable.  Either  the  systolic 
or  diastolic  sound  may  be  heard,  to  the  exclusion  of  the  other,  and 
both  may  be  wanting.  The  latter  is  likely  to  occur  under  the  same 
combination  of  physical  circumstances  which  renders  an  impulse 
extremely  feeble  or  inappreciable. 

The  auscultatory  signs  referable  to  the  trachea,  bronchi,  and  pul- 
monary organs  are  due  to  compression  of  these  parts  by  the  aneu- 
rismal sac.  These  signs  may  be  present  before,  as  well  as  after,  the 
appearance  of  an  external  tumor.  They  are  of  considerable  im- 
portance in  determining  the  existence  and  seat  of  aneurism. 

Pressure  on  the  lower  part  of  the  trachea  gives  rise,  as  already 
stated,  to  wheezing  or  stridulous  breathing,  which  may  sometimes 
be  perceived  at  a  distance  from  the  patient.  If  the  voice  be  not 
affected,  it  is  evident  that  it  proceeds  from  a  point  below  the  larynx. 
But  if  there  be  room  for  doubt,  the  stethoscope  indicates  that  it  is 
from  below.  It  may  be  produced  in  the  bronchus  on  one  side 
before  the  aneurismal  tumor  ascends  sufficiently  to  press  upon  the 
trachea.  It  may  be  perceived,  especially  if  produced  in  a  bronchus, 
and  referred  to  its  seat,  by  means  of  auscultation,  when  it  is  not 
loud  enough  to  be  apparent  without  the  aid  of  the  stethoscope.  Dr. 
Stokes  distinguishes  this  sign  as  '■'■  stridor  from  heJowr  It  is  obvious 
that  it  may  be  produced  by  a  tumor  of  any  kind  making  pressure 
on  the  trachea  or  bronchi.  The  practical  point  is  to  determine,  by 
auscultation,  that  a  wheezing  sound,  either  audible  at  a  distance,  or 
heard  with  the  stethoscope  only,  is  produced,  not  at  the  larynx  or 
the  upper  part  of  the  trachea,  but  below,  at  the  bifurcation  or  in  a 
bronchus.  If  dyspnoea  or  labored  respiration  exist,  the  seat  of  the 
obstruction  is  thus  ascertained.  The  existence  of  a  tumor  pressing 
upon  the  air-tubes  in  this  situation  is  rendered  highly  probable, 


DIAGNOSIS    OF    THOKACIC    ANEUEISMS.  457 

and  it  remains  for  the  aneurismal  character  of  the  tumor  to  be 
shown  by  other  signs. 

An  aneurismal  tumor  may  compress  a  bronchus  so  as  to  dimi- 
nish, and  even  suppress,  respiration  in  one  lung.  Absence  of  the 
respiratory  murmur  on  one  side,  or  a  marked  disparity  in  the 
intensity  of  the  murmur  between  the  two  sides,  may  thus  become 
important  signs  of  the  existence  and  degree  of  bronchial  obstruc- 
tion. The  significance  of  these  signs  depends,  of  course,  on  the 
absence  of  causes  of  diminished  or  suppressed  respiration  on  one 
side,  other  than  occlusion  or  narrowing  of  a  bronchus  by  the 
pressure  of  a  tumor.  Bronchitis,  emphysema,  pleurisy  with  effa- 
sion,  and  the  presence  of  a  foreign  body,  are  to  be  excluded.  That 
the  obstruction  is  not  due  to  enlarged  bronchial  glands,  or  intra- 
thoracic tumor  not  aneurismal,  is  to  be  determined  by  other  signs 
pointing  to  the  existence  of  aneurism. 

Finall}^,  absence  of  the  respiratory  murmur  and  of  vocal  reso- 
.  nance  over  a  circumscribed  space,  or  around  an  external  tumor, 
concurs  with  the  evidence  afforded  by  percussion,  either  in  render- 
ing probable  the  existence  of  a  tumor  within  the  chest,  not  apparent 
to  the  eye,  or,  if  visible,  in  determining  the  space  within  the  chest 
which  the  tumor  occupies,  to  the  exclusion  of  the  pulmonary 
organs. 


Diagnosis  of  Thoracic  Aneurisms. 

A  reviewal  of  the  preceding  pages  will  show  that  the  symptoma- 
tology of  thoracic  aneurism  furnishes  nothing  exclusively  distinc- 
tive of  this  affection ;  that  is  to  say,  there  are  no  symptoms  or  signs 
which  are  individually  pathognomonic.  An  impulse  over  a  cir- 
cumscribed space  at  certain  points,  distinct  from  the  apex-beat,  or 
a  pulsating  tumor,  renders  the  presumption  strong  that  aneurism 
exists;  but  additional  evidence  is  necessary  for  a  positive  diagnosis. 
Even  if  bellows  murmur  and  thrill  are  added,  the  existence  of  aneu- 
rism is  not  unquestionable.  The  diagnostic  force  of  these  signs 
depends  considerably  on  their  degree  of  prominence.  If  they  be 
combined  and  strongly  marked,  the  chances  against  aneurism  are 
small.  If,  in  addition,  the  point  at  which  an  impulse  or  a  pulsating 
tumor  is  observed  correspond  with  the  situation  in  which  an  aneu- 
rism springing  from  the  aorta  may  be  expected  to  be  discovered  ;  and 
if  percussion  and  auscultation  show  the  presence  of  an  intra-thoracic 


458  THORACIC    ANEURISMS. 

tumor  wliich  can  be  traced  in  a  direction  toward  the  aorta,  there  is 
scarcely  room  for  doubt  as  to  the  diagnosis.  These  diagnostic 
points  are  by  no  means  always  available.  An  aneurism  may  be 
so  situated  as  regards  the  thoracic  walls,  that  an  impulse  is  not 
appreciable,  or,  if  there  be  a  tumor,  it  may  not  pulsate,  nor  present 
either  murmur  or  thrill.  On  the  other  hand,  a  tumor  not  aneuris- 
mal,  may  present  murmur,  pulsation,  and  thrill.  The  situation  of 
the  tumor  is  a  point  of  considerable  importance.  Bearing  in  mind 
that,  in  the  great  majority  of  cases,  aneurism  springs  from  the 
ascending  or  transverse  portion  of  the  aorta,  and  makes  its  appear- 
ance externally  either  to  the  right  of  the  sternum,  or  at  the  upper 
or  middle  portion  of  the  sternum,  or  to  the  left  of  this  bone,  a 
tumor  thus  situated  is  likely  to  prove  to  be  aneurismal.  If  not 
aneurismal,  it  is  probably  a  carcinomatous  mediastinal  tumor.  The 
latter  lying  over  the  aorta  may  pulsate  pretty  strongly,  and  by 
pressing  on  the  artery  may  develop  a  bellows  murmur.  Carcino- 
matous disease,  however,  in  this  situation  is  a  much  rarer  affection 
than  aneurism,  so  that  the  chances  of  the  latter  preponderate.  Age 
and  sex  are  to  be  taken  into  account.  A  tumor  occupying  a  site  in 
which  an  aneurism  is  apt  to  make  its  appearance,  is  more  likely 
to  prove  to  be  aneurismal  if  the  patient  be  a  male  and  between  the 
ages  of  thirty  and  sixty.  In  general,  with  proper  knowledge  and 
care,  taking  into  view  all  the  circumstances  of  the  case,  if  an 
aneurismal  tumor  be  apparent  externally,  its  character  may  be 
ascertained  without  great  difficulty,  and  the  diagnosis  made  with 
positiveness.  It  is  hardly  necessary  to  notice  the  differential  points 
which  distinguish  an  aneurismal  tumor  from  pulsating  empyema, 
or  pericarditis  with  effusion,  for  the  existence  of  these  affections  is 
readily  determined  by  their  proper  diagnostic  characters. 

An  aneurism  not  in  contact  with  the  thoracic  walls  so  as  to  give 
rise  to  an  impulse  appreciable  by  the  eye  or  touch,  and  not  forming 
an  external  tumor,  offers  a  more  difficult  problem  in  diagnosis. 
Certain  symptoms  which  have  been  considered,  viz.,  embarrassed 
or  stridulous  breathing,  dysphagia,  venous  congestion  of  the  face 
and  upper  extremities,  and  inequality  of  the  pulse  on  the  two  sides, 
should  excite  suspicion  of  aneurism,  especially  if  they  are  found  in 
combination,  and,  also,  individually,  provided  they  are  not  obviously 
referable  to  other  morbid  conditions.  Physical  exploration,  under 
these  circumstances,  is  essential,  not  alone  in  developing  signs 
which  point  directly  to  the  existence  of  aneurism,  but  by  showing 
that  other  morbid  conditions  which  would  account  for  the  symp- 


DIAGNOSIS    OF    THOEACIC    ANEUKISMS.  459 

toms,  do  not  exist,  and  thus  leading  to  a  diagnosis,  indirectly,  by 
way  of  exclusion.  The  chest  is  to  be  carefully  examined  with 
reference  to  cardiac  disease,  since  the  symptoms  and  physical  signs 
of  aneurism  of  the  ascending  and  transverse  aorta  have  many 
points  in  common  with  those  referable  to  the  heart.  The  absence 
of  cardiac  murmurs  and  of  enlargement  of  the  heart  warrants  the 
conclusion  that  the  symptomatic  phenomena  are  not  due  to  lesions 
of  this  organ.  But  even  if  the  heart  be  not  altogether  free  from 
disease,  it  may  be  sufficiently  clear  that  certain  symptoms  and  signs 
are  not  of  cardiac  origin.  Thus,  a  mitral  regurgitant  murmur  is 
easily  distinguished  from  a  murmur  referable  to  the  aorta ;  and  the 
amount  of  enlargement  of  the  heart  may  be  obviously  inadequate 
to  account  for  the  disturbance  of  the  respiration  and  circulation. 
Auscultation  of  the  lungs  and  air-passages  is  to  be.  employed  in 
order  to  ascertain  whether  the  respiratory  murmur  be  diminished 
or  suppressed  on  one  side  from  compression  of  a  bronchus,  and 
whether  the  respiratory  sound  in  the  larynx  and  trachea  be  pure. 
If  stridulous  breathing  be  heard,  with  or  without  the  stethoscope, 
this  instrument  will  show  the  point  at  which  it  is  produced,  and 
thus  indicate  the  seat  of  the  obstruction.  Percussion  and  ausculta- 
tion conjoined  are  to  be  resorted  to  in  order  to  ascertain  whether 
there  be  not  dulness,  together  with  absence  of  the  respiratory  mur- 
mur and  vocal  resonance,  within  a  circumscribed  space,  so  situated 
that  the  presence  of  a  tumor  having  relations  to  the  aorta  similar 
to  those  which  aneurisms  are  known  to  have,  is  rendered  highly 
probable  or  almost  certain.  A  bellows-murmur  either  localized 
in  this  circumscribed  space, or  heard  herewith  maximum  intensity, 
and  the  heart-sounds  abnormally  transmitted  to  the  same  space, 
are  signs  entitled  to  a  certain  amount  of  weight.  Availing  himself 
of  the  diagnostic  points  just  recapitulated,  the  diagnostician  may 
be  able  to  decide  on  the  existence  of  aneurism,  not  with  absolute 
certainty,  but  with  much  positiveness.  The  liability  to  error  pro- 
ceeds from  the  possibility  of  enlarged  bronchial  glands,  or  intra- 
thoracic tumor  of  some  kind,  not  aneurismal,  pressing  on  the 
trachea,  or  a  bronchus,  the  subclavian  or  innominata,  the  recurrent 
nerve,  the  oesophagus,  and  the  vena  cava,  so  as  to  give  rise  to  more 
or  less  of  the  symptoms  and  signs  due  to  the  pressure  of  an  aneu- 
rismal tumor  on  these  parts.  The  probability  of  the  tumor  being 
aneurismal  is  considerably  increased  if  the  patient  be  over  thirty 
years  of  age  and  of  the  male  sex. 

In  connection  with  the  subject  of  diagnosis,  it  may  not  be  amiss 


460  TIIOIIACIC    ANEUKISMS. 

to  call  attention  to  the  importance  of  examining  for  a  visible  im- 
pulse with  the  eye  brought  to  a  level  with  the  surface  of  tlie  chest; 
and,  for  a  tactile  impulse,  with  one  hand  applied  to  the  posterior, 
and  the  other  to  the  anterior  portion  of  the  chest,  making  firm 
pressure  with  the  latter  hand.  On  the  very  day  this  paragraph  is 
penned,  a  case  has  fallen  under  my  observation  in  which  an  impulse 
was  rendered  apparent  to  the  eye  and  touch  by  these  methods  of 
examination  only.  It  is  true  that  an  impulse  is  not  proof  positive 
of  the  existence  of  aneurism,  but,  even  if  not  strongly  marked,  its 
value  as  a  diagnostic  sign  is  considerable.  It  may  be  important  to 
caution  the  young  observer  against  mistaking  pulsation  of  the  sub- 
clavian artery  for  an  aneurismal  impulse.  It  is  to  be  borne  in 
mind  that  pulsation  of  this  artery  is  sometimes  visible  and  felt,  and 
especially  in  cases  of  disease  of  the  heart  involving  aortic  regurgi- 
tation ;  but,  under  the  latter  circumstances,  the  carotid  and  other 
arteries  are  observed  at  the  same  time  to  pulsate  strongly. 

Symptoms  and  signs  pointing  to  the  existence  of  aneurism,  are 
far  less  available  for  diagnosis  when  the  aneurismal  tumor  springs 
from  the  descending  aorta,  than  when  it  is  seated  at  the  ascending 
portion  or  arch  of  the  vessel.  As  regards  symptoms,  labored  and 
stridulous  breathing,  aphonia  or  hoarseness,  venous  congestion  of 
the  upper  portion  of  the  body,  and  inequality  of  the  pulse,  are  not 
produced  unless  the  tumor  attains  to  a  great  size.  Dysphagia  from 
obstruction  of  the  oesophagus  is  liable  to  occur,  and  this  symptom, 
when  not  connected  with  disease  of  the  pharynx,  should  always 
excite  suspicion  of  aneurism.  The  frequent  occurrence  of  persist- 
ing, boring  or  gnawing  pain  referred  to  a  particular  portion  of  the 
spinal  column,  is  to  be  borne  in  mind.  This  should  suggest  to  the 
mind  the  possibility  of  aneurism.  The  same  is  to  be  said  of  a  dis- 
position to  keep  the  body  bent  forward,  in  consequence  of  pain  in 
assuming  the  erect  posture,  and  of  the  occurrence  of  paraplegia,  the 
latter  proceeding  from  erosion  of  the  vertebra  by  the  pressure  of 
the  aneurismal  tumor.  As  regards  signs,  obstruction  of  the  trachea 
or  a  bronchus,  and  diminished  respiratory  murmur  on  one  side,  are 
not  likely  to  occur  in  cases  of  aneurism  seated  in  the  descending 
aorta.  But  percussion  in  the  interscapular  space  may  show  dulness 
within  a  circumscribed  area,  the  limits  of  which  may  also  be  de- 
fined by  abrupt  cessation  of  respiratory  murmur  and  of  vocal 
resonance.  A  bellows-murmur  may  be  discovered,  within  this 
area,  not  transmitted  from  the  heart,  and  possibly  the  heart-sounds 
may  be  unduly  audible.     These  signs  are  not  conclusive,  but  they 


TREATMENT    OF    THORACIC    ANEURISMS.  461 

point  to  the  existence  of  aneurism.  A  positive  diagnosis  is  hardly 
practicable  prior  to  the  development  of  external  bulging  or  a  pul- 
sating tumor.  So  latent  are  aneurisms  in  this  situation  in  some 
cases  that,  although  symptoms  denoting  some  indefinite  ailment 
have  been  long  experienced,  an  external  tumor  may  be  the  first 
event  which  excites  suspicion  of  the  nature  of  the  disease.  Phy- 
sical exploration  is  of  great  value  in  these  cases  by  enabling  the 
diagnostician  to  exclude  certain  affections,  for  example,  chronic 
pleurisy  or  empyema,  for  which,  otherwise,  the  disease  might  be 
mistaken. 


Treatment  op  Thoracic  Aneurism. 

Recovery  from  thoracic  aneurism  is  possible.  The  chances 
against  recovery,  however,  preponderate  so  vastly  that  in  any 
given  case  there  is  scarcely  ground  to  hope  for  this  result.  Still,  the 
possibility  of  recovery  is  not  to  be  lost  sight  of  in  the  management 
of  the  cases  which  it  is  the  misfortune  of  the  physician  to  meet 
with  in  practice.  But  although  recovery  is  not  to  be  looked  for,  the 
progress  of  the  affection  may  be  more  or  less  slow,  and  the  physi- 
cian may  reasonably  hope  to  contribute,  by  judicious  management, 
to  postpone  for  an  indefinite  period  the  fatal  result.  Moreover,  the 
palliation  of  distressing  symptoms,  always  an  important  object  of 
treatment,  furnishes  scope,  in  the  progress  of  this  affection,  for  the 
useful  application  of  remedies. 

Recovery  fi'om  thoracic  aneurism  can  only  be  effected  by  the 
deposit  within  the  sac  of  successive  layers  of  solid  fibrin  until  the 
cavity  is  obliterated,  le&,ving  the  channel  of  the  artery  free.  Can 
this  curative  process  be  promoted  by  medical  treatment  ?  There 
are  no  medicines  which  exert  a  special  effect  for  this  end.  The 
general  conditions  favorable  for  the  process  are,  an  abundance  of 
the  fibrinous  constituent  of  the  blood,  with  an  equable  and  not  too 
active  state  of  the  circulation.  These  are  conditions  which  are  to 
some  extent  controllable.  Those  which  depend  on  local  circum- 
stances, such  as  the  size  and  shape  of  the  cavity,  the  form  and 
direction  of  the  aperture,  the  state  of  the  interior  of  the  sac  as 
regards  roughness,  etc.,  are  obviously  beyond  control.  The  indi- 
cations for  treatment,  then,  with  a  view  to  the  possibility  of  reco- 
very are,  to  maintain  and  perhaps  increase  the  relative  proportion 
of  the  fibrinous  constituent  of  the  blood,  and  to  secure  regularity 


462  THORACIC    ANEURISMS. 

of  the  action  of  the  heart,  obviating,  on  the  one  hand,  over-excite- 
ment, and,  on  the  other  hand,  undue  feebleness.  How  are  these 
indications  to  be  fulfilled  ?  In  brief,  by  a  nutritious,  and,  in  some 
instances,  a  generous  diet,  embracing  a  good  proportion  of  animal 
food ;  by  tonic  remedies  and  stimulants  when  the  appetite  and 
digestive  powers  are  enfeebled ;  and  by  the  restricted  use  of 
liquids  which,  by  increasing  the  quantity  of  blood,  lessen  the 
proportion  of  fibrin  to  the  mass.  These  measures  relate  to  the  first 
indication,  viz.,  to  maintain  or  increase  the  fibrin.  The  second 
indication,  viz.,  to  secure  regularity  of  the  heart's  action,  is  to  be 
fulfilled  by  avoiding  active  exercise,  mental  excitement,  and  other 
causes  inducing  disturbance  or  undue  activity  of  the  circulation ; 
by  moderate  depletion  by  means  of  saline  laxatives,  or  resorting 
perhaps  in  some  cases  to  small  bleedings  if  decided  plethora  exist, 
but,  on  the  other  hand,  prescribing  ferruginous  remedies  if  anaemia 
be  present;  and  by  the  use  of  sedatives  if  the  circulation  be  unduly 
and  persistingly  over-excited. 

These  indications,  having  reference  to  the  possibility  of  recovery, 
relate  not  less  to  an  object  of  management  more  likely  to  be 
attained,  viz.,  to  retard  the  progress  of  the  afi'ection,  and  thus  post- 
pone the  fatal  result.  This  object  is  alike  secured  by  the  deposit 
of  fibrin  within  the  aneurismal  cavity,  by  which  the  walls  of  the 
sac  are  strengthened,  and  the  tendency  to  its  enlargement  thereby 
lessened,  and  by  tranquillity  of  the  heart's  action.  The  means, 
then,  by  which  the  physician  may  hope  to  prolong  life  are  those 
which,  at  the  same  time,  afford  the  best  chance,  slight  as  this  is,  of 
recovery. 

Potent  measures  of  treatment  have  been  heretofore  advised  and 
pursued  with  the  expectation  of  retarding  the  progress  of  thoracic 
aneurisms  and  with  a  faint  hope  of  effecting  a  cure.  The  plan  of 
treatment  introduced  about  half  a  century  ago  by  Albertini  and 
Valsalva,  adopted  by  Laennec  and  Bouillaud,  and  recommended  in 
a  modified  form  by  Hope,  obtained  more  favor  and  currency  than 
any  other.  This  plan  consisted  in  repeated  copious  bleedings,  as 
much  quietude  as  possible  of  body  and  mind,  and  reduction  of  the 
diet  to  the  lowest  point  compatible  with  life.  It  is  unnecessary  to 
show  the  false  basis  of  this  plan,  or  its  pernicious  results,  since  it 
is  now  abandoned  by  all  judicious  practitioners;  nor  is  it  likely 
that  any  method  involving  measures  of  equal  potency,  if  proposed, 
would  meet  with  favorable  consideration.  On  this  subject,  the 
remarks  by  Dr.  Stokes  are  so  just  and  forcible  that  I  shall  quote 


TREATMENT    OF    THORACIC    ANEURISMS.  463 

liis  words:  "It  is  to  be  doubted  whether  we  are  ever  justified  in 
adopting  any  measures  which,  while  they  are  directed,  under  theo- 
retical views,  to  the  cure  of  the  disease,  materially  interfere  with 
the  patient's  condition.  It  often  happens  that  a  patient  who  has 
not  been  thus  interfered  with  will  continue  with  unimpaired  health 
and  strength  for  a  great  length  of  time  until  he  is  so  unfortunate  as 
to  be  placed  under  treatment  for  the  cure  of  his  aneurism.  For 
then  all  the  evils  which  have  been  pointed,  out  as  occurring  in 
cases  of  indolent  disease  of  the  heart,  when  injured  by  ignorant 
treatment,  are  induced.  The  patient's  mind  becomes  excited  and 
apprehensive,  his  system  is  weakened  by  depletion,  and  his  digest- 
ive functions  ruined  by  starvation.  The  forces  by  which  he  can 
resist  disease  are  broken  down,  his  blood  becomes  uncoagulable, 
his  tissues  unresisting.  The  force  of  the  aneurismal  throb  is 
augmented,  and  a  disease  which,  under  other  circumstances,  might 
have  endured  for  years  with  but  little  interference  with  the  general 
health,  is  turned  into  a  rapid  and  destructive  malady.'" 

Pursuing  no  special  plan  of  treatment,  the  management  must 
depend  very  much  on  the  circumstances  pertaining  to  individual 
cases.  Is  the  patient  of  a  full  plethoric  habit,  the  vessels  over- 
repleted,  and  the  heart  over-stimulated;  depletion  may  be  called 
for,  care  being  taken  not  to  carry  it  beyond  the  point  of  restoring 
the  blood  to  its  normal  condition.  Is  the  patient  anaemic,  and  the 
heart's  action  excited  by  impoverished  blood ;  a  nutritious,  animal 
diet,  together  with  preparations  of  iron  and  perhaps  porter,  wine,  or 
spirits,  are  important,  being  careful  not  to  push  these  measures  to  an 
extreme,  and  thereby  induce  evils  equal  to  those  incident  to 
anaemia.  Is  the  appetite  good  and  digestion  active;  indulgence  at 
the  table  is  to  be  restrained.  On  the  other  hand,  is  the  appetite 
poor  and  digestion  weak ;  measures  to  improve  both  are  indicated. 
The  restricted  use  of  liquids  is  an  important  point  in  the  manage- 
ment, conducing,  in  connection  with  an  appropriate  diet,  to  the 
formation  of  blood  rich  in  fibrin,  and  not  excessive  in  quantity. 
These  ends  are  promoted  by  a  limited  supply  of  liquid,  far  better  than 
by  the  elimination  of  liquid  by  means  of  hydragogue  cathartics 
and  diuretics. 

A  regular  and  tranquil  condition  of  the  heart  being  highly 
desirable  in  all  cases,  everything  which  excites  unduly  this  organ 
is,  of  course,  as  far  as  possible,  to  be  avoided.     Active  muscular 

'  Op.  cit.,  p.  606. 


464  THORACIC   ANEURISMS. 

exercise,  mental  excitement,  the  abuse  of  alcoholic  stimulants,  etc., 
are  to  be  interdicted.  It  is  an  important  question,  in  this  connec- 
tion, how  far  exercise  can  be  taken  with  safety  or  advantage. 
Some  writers  recommend  perfect  quietude,  and  enjoining  the 
patient  to  remain  a  considerable  portion  of  the  time  in  the  recum- 
bent posture.^  The  propriety  of  this  is  more  than  doubtful.  The 
appetite,  digestion,  and  general  condition  of  the  body  must  sufi'er 
from  such  inaction,  so  that  the  risk  of  doing  harm  by  impoverishing 
the  blood  and  weakening  the  vital  forces,  is  greater  than  the  lia- 
bility to  injury  from  moderate  exercise.  An  amount  of  exercise 
which  can  be  taken  without  accelerating  the  circulation,  will  be 
likely  to  be  useful  rather  than  injurious. 

An  important  point  in  the  treatment  concerns  the  mental  con- 
dition of  the  patient.  A  full  knowledge  of  the  nature  of  the 
affection,  and  of  the  accidents  to  which  he  is  exposed,  can  hardly 
fail,  in  most  cases,  to  induce  depression  and  apprehension,  the  effect 
of  which  must  be,  to  a  certain  extent,  unfavorable.  When  it  can 
be  done  without  breach  of  good  faith,  or  a  violation  of  truth,  the 
physician  will  do  wisely  in  forbearing  to  enter  into  an  elaborate 
exposition  of  the  character,  tendencies,  and  results  of  thoracic 
aneurisms.  AVhile  deception  here,  as  in  other  forms  of  disease,  is 
unworthy  the  character  of  a  physician,  as  well  as  unjust  to  the 
patient,  it  is  fair  to  present  as  favorable  a  view  of  the  case  as  facts 
will  warrant.  The  patient  may  be  encouraged  with  the  hope  of 
the  affection  progressing  very  slowly,  or  remaining  stationary  for 
an  indefinite  period,  and  even  with  the  possibility  of  recovery.  He 
will  thus  be  spared  not  only  a  portion  of  the  unhappiness  to  which 
the  affection  is  calculated  to  give  rise,  but  the  unfavorable  influence 
of  excessive  anxiety  and  gloom ;  and  he  will,  moreover,  be  more 
disposed  to  persevere  in  following  faithfully  regulations  of  diet  and 
regimen. 

If  the  action  of  the  heart  be  habitually  excited  or  irregular, 
sedative  remedies  are  indicated,  such  as  hydrocyanic  acid,  aconite, 
hyoscyamus,  opium  in  small  doses,  etc.  It  is  considered  by  some 
writers  injudicious  to  resort  to  digitalis  for  this  purpose;  but  I  can 
see  no  just  grounds  for  apprehending  evil  from  the  use  of  this 
remedy,  if  proper  caution  be  observed.  Here,  as  in  other  instances 
in  which  it  is  desirable  to  reduce  the  frequency  of  the  heart's  action, 
it  is  a  remedy  of  great  value. 

'  e.  g.  Bellingham,  op.  cit. 


I 


TREATMENT    OF    THORACIC    ANEURISMS.  465 

Certain  remedies  are  recommended  with  a  view  to  induce  a  con- 
dition of  the  blood  favoring  the  coagulation  of  the  fibrin.  Dr. 
Hope  regarded  the  acetate  of  lead  as  useful  in  this  way ;  and  Dr. 
Walshe  attaches  some  value  to  gallic  or  tannic  acid.  Theoretically, 
remedies  are  indicated  which  produce  this  effect,  provided  it  be  not 
counterbalanced  by  other  consequences.  It  is,  however,  doubtful 
whether  these  or  other  known  remedies  produce  this  effect ;  and, 
moreover,  it  is  to  be  considered  that  ordinary  coagulation  of  blood 
within  the  sac,  so  far  from  being  desirable,  would  be  likely  to  give 
rise  to  serious  results.  Coagulation  is  conservative  and  curative 
only  when  it  takes  place  at  the  bottom  of  the  sac,  leading  to  the 
formation  of  layers  of  fibrin,  which  become  adherent  first  to  the 
walls  of  the  sac,  and  successively  to  each  other,  until  the  cavity  is 
more  or  less  filled  with  the  solid  deposit. 

The  various  symptomatic  and  remote  effects  of  thoracic  aneu- 
risms, such  as  pain,  cerebral  congestion,  labored  respiration,  cough, 
dysphagia,  etc.,  will,  of  course,  claim  palliative  measures  of  treat- 
ment, which  are  to  be  adapted  to  the  particular  circumstances  of 
individual  cases,  and  need  not  be  here  considered. 


30 


INDEX. 


A 


Adhesions  of  pericardium,  289,  336,  360 
effects  on  the  heart  and  circulation, 

361 
how  ascertained  during  life,  366 
Albuminuria  in  dilatation,  81 
in  valvular  lesions,  172 
in  pericarditis,  292 
Antemia  in  valvular  lesions,  175,  223 

in   connection  with    enlargement   of 
thyroid  body  and  prominence  of  the 
eyes,  268,  272 
in  functional  disorder  of  the  heart, 
405 
Aneurism,  cardiac,  112 
Aneurisms,  thoracic,  436 
varieties  of,  437 
anatomical  relations  of,  439 
formation  and  causes  of,  441 
terminations  of,  442 
symptoms  of,  443 
physical  signs  of,  450 
diagnosis  of,  457 
treatment  of,  461 
Angina  pectoris,  254 
description  of,  255 
pathological  character  and  relations 

of,  258 
infrequency  of,  261 
prognosis,  261 
diagnosis,  262 
treatment,  264 
Aortic  lesions,  120 

anatomical  characters,  120 
frequency  of,  123 
effect  on  left  ventricle,  129 
on  heart- sounds,  207 
diagnostic  characters  of,  211 
valve,  water  test  of  sufficiency  of,  123 
orifice,  normal  size  of,  124 
regurgitation,  129 
contraction,  129 
direct  or  systolic  murmur,  190 
regurgitant  or  diastolic  murmur,  191 
Aorta,  diseases  of,  429 
inflammation  of,  429 
morbid  deposit  on  lining  membrane 

of,  432 
atheromatous  deposit  in,  432 
calcareous  degeneration  in,  433 
dilatation  of,  435 


Apex-beat,  normal  situation  and  devia- 
tions of,  45 

normal  force  of,  46 

mechanism  of,  46 

altered  situation  in  enlargement  of 
heart,  49 

enlarged  area  of,  in  enlargement  of 
heart,  50 

increased  force  of,  in  hypertrophy, 
50,  411 

in  dilatation,  82 

in  pericarditis,  326,  354 

in  pericardial  adhesions,  367 

in  functional  disorder,  411 
Aphonia  in  thoracic  aneurisms,  445 
Apoplexy  in  connection  with  hypertrophy, 
34 

in  connection  with  valvular  lesions,  164 

pseudo,  in  fatty  degeneration,  96 

pulmonary,  in  valvular  lesions,  159 
Arcus  senilis  in  fatty  degeneration,  97 
Arteries,  obstruction  of,  by  fibrinous  de- 
posits from  valves  and  orifices,  151, 165, 
382,  431 
Asthma,  cardiac,  80,  157,  174,  257 
Attrition,  sounds  of,  in  pericarditis,  316 
Atrophy  with  diminished  bulk,  88 
Atheroma  in  aorta,  432 
Auscultation  in  hypertrophy,  58,  71 

in  dilatation,  83,  85 

in  fatty  degeneration,  100 

in  pericarditis,  316,  330,  354 

in  pericardial  adhesions,  367 

in  endocarditis,  386 

in  functional  disorder,  412 

in  thoracic  aneurisms,  454 

B 

Bellingham  on  size  of  the  orifices  of  the 

heart,  124 
Beau  on  digitalis,  102 
Becquerel  on  cirrhosis  and  valvular  le- 
sions, 170 
Begbie  on  prominence  of  eyes,  267,  272 
Bizot,  measurements  of  heart,  20 

of  orifices,  124 
Blakiston  on  cardiac  dropsy,  149 
Blisters  in  pericarditis,  343,  349,  350 
Blood-currents,  vide  currents  of  blood 
Bloodletting  in  hypertrophy,  74 

in  dilatation,  85 


468 


INDEX. 


Bloodletting  in  fatty  degeneration,  102 

in  valvular  lesions,  222 

in  acute  pericarditis,  339,  347 

in  endocarditis,  393,  396 

in  functional  disorder,  422 

in  thoracic  aneurisms,  462 
Blue  disease,  vide  cyanosis 
Bouillaud,  mode  of  percussion,  39 

on  rupture  of  interventricular  septum, 
233 

on  reduplication  of  the  heart-sounds, 
274,  277 
Brain,  symptoms  referable  to,  in  pericar- 
ditis, 306 
Bruit  de  diable,  204 

de  cuir  neuf,  316 
Bright's  disease  in  dilatation,  81 

in  valvular  lesions,  172 

in  pericarditis,  292 

in  endocarditis,  379 
Bronchitis  in  valvular  lesions,  161 
Burrows  on  cerebral  symptoms  in  pericar- 
ditis, 306 
Budd  on  cirrhosis  and  valvular  lesions,  170 


Carcinoma  of  heart,  117 
Cathartics  in  pericarditis,  350 

in  endocarditis,  394 

in  valvular  lesions,  227 
Calcareous  degeneration  in  aorta,  433 
Carditis,  399 

Cerebral  symptoms  in  pericarditis,  306 
Chambers  on  relative  frequency  of  aortic 
and  mitral  lesions,  123 

on  pericarditis  and  pyfemia,  294 

on  pericardial  adhesions,  361 
Cheyne  on  respiratory  movements  in  fatty 

degeneration,  97 
Charcelay  on  reduplication  of  heart-sounds, 

275,  278 
Chevers  on  cyanosis,  241 

on  pericardial  adhesions,  365 
Christison  on  external  use  of  diuretics,  227 
Cirrhosis  of  liver  in  valvular  lesions,  170 
Clark  and  Caramann,  results  of  ausculta- 
tory percussion,  40 
Clendinning  on  weight  of  heart,  23 
Clark,  case  of  pericarditis,  353 
Cliquement  metallique,  414 
Coagula  in  cavities  of  the  heart  in  endo- 
carditis, 383 

in  dilatation,  82 
Cor  bovinum,  130 

Coronary  arteries,  obstruction  of,  in  val- 
vular lesions,  132 
Collin,  bruit  de  cuir  neuf,  317 
Congestion  of  lungs  in  valvular  lesions,  155 

of  liver,  168 

of  kidneys,  172 

capillary,  in  valvular  lesions,  175 
Corrigan  on  aortitis,  430 
Cough  in  valvular  lesions,  158 


Cough  in  pericarditis,  303 
Complexion  in  valvular  lesions,  175 
Coagula  and  clots  in  cavities  of  the  heart, 
245 
formed  after  death,  245 

during  life,  24G 
conditions  of  formation,  248 
symptoms  of,  250 
physical  signs  of,  257 
diagnosis  of,  251 
prognosis  of,  252 
treatment  of,  252 
Congenital  malformations,  vide  malforma- 
tions 
Corson  on  nux  vomica  in  valvular  lesions, 

224 
Counter-irritation  in  pericarditis,  343,  349, 
350 
in  endocarditis,  395,  397 
Crisp  on  thoracic  aneurisms,  442 
Currents  of  blood,  185 
Current,  direct  mitral,  185 
aortic,  185 
regurgitant  mitral,  185 
aortic,  185 
Cyanosis  in  valvular  lesions,  174 
in  malformations,  238 
explanation  of,  240 
diagnosis  of,  243 
prognosis  of,  243 
connection  of  pericarditis  with,  295 

D 

Dalton  on  elongation  of  heart  in  systole.  47 

on  rapidity  and  extent  of  physical  and 
chemical  changes,  397 
Decubitus  in  pericarditis,  305 
Defects  of  heart,  vide  malformations 
Delirium,  etc.,  in  pericarditis,  306 

cases  observed  by  author,  307 
Dilatation,  definition  and  different  forms 
of,  18 

mode  of  production,  77 

symptoms  and  effects  of,  80 

physical  signs  of,  84 

summary  of  physical  signs  of,  84 

treatment  of,  85 

of  left  ventricle  from  aortic  regurgita- 
tion, 129 
Digestion,  disorder  of  in  valvular  lesions, 

170 
Diastolic  murmurs,  186,  197 

mitral  direct  murmur,  186 

aortic  regurgitant  murmur,  191 
Diet  in  valvular  lesions,  222 

in  acute  pericarditis,  349 

in  endocarditis,  394,  398 
Digitalis  in  valvular  lesions,  224 

in  hypertrophy,  76 

in  fatty  degeneration,  102 

in  pericarditis,  343 

in  endocarditis,  395 

in  functional  disorder,  427 


INDEX. 


469 


Digitalis  in  thoracic  aneurisms,  464 
Diuretics  in  cardiac  dropsy,  226 

external  use  of,  227 

in  pericarditis,  850 
Dropsy  in  hypertrophy,  35 

in  dilatation,  81 

in  valvular  lesions,  147 

treatment  of,  225 
Dyspnoea  in  hypertrophy,  33 

in  dilatation,  80 

in  fatty  degeneration,  95 

in  valvular  lesions,  156,  174 

in  angina  pectoris,  255 

in  pericarditis,  303 

in  thoracic  aneurisms,  444 
Dysphagia  in  pericarditis,  304 

in  thoracic  aneurisms,  446 
Dyspepsia  in  functional  disorder  of  heart, 
408 


Ectopia  pectoralis  cordis,  231 
cordis  ventralis,  231 
cephalica,  231 
Eliminatives  in  pericarditis,  346,  348,  350 

in  endocarditis,  395,  396 
Emphysema  of  lungs,  affecting  the  signs 
of  enlargement,  43 
a  cause  of  enlargement,  28,  130 
in  valvular  lesions,  161 
Embolia,  151,  165,  382,  431 
Enlargement  of  the  heart,  17 
different  forms  of,  18 
by  hypertrophy  and  dilatation,  19 
physical  signs  of  by  percussion,  41 
by  palpation,  45 
by  auscultation,  58 
by  inspection,  67 
by  mensuration,  68 
summary  of  physical  signs  of,  70 
diagnosis  of,  69 
by  dilatation,  77 

mode  of  production  of,  77 
symptoms  and  effects  of,  80 
physical  signs  of,  82 
diagnosis  of,  84 

summary  of  physical  signs  of,  84 
treatment  of,  85 
Enterorrhoea  in  valvular  lesions,  171 
Endocarditis,  370 

anatomical  characters  of,  371 
pathological  relations  and  causation 

of,  377 
artificial  production  of,  381 
formation  of  coagula  in,  383 
symptoms  of,  384 
physical  signs  of,  385 
diagnosis  of,  390 
prognosis,  392 
treatment  of,  393 
Endo-pericarditis,  377,  379 
Epistaxis  in  valvular  lesions,  171 
Erythema  in  valvular  lesions,  175 
Expectoration  in  valvular  lesions,  158 


Exocardial  sounds,  vide  friction-sounds 
Exercise  in  hypertrophy,  73 
in  dilatation,  86 
in  fatty  degeneration,  105 
in  valvular  lesions,  221 
in  functional  disorder,  423 
Eyes,  prominence  of,  267,  270 

case  observed  by  author,  271 
prognosis,  273 
treatment,  273 
contraction  of  in  thoracic  aneurisms, 
450 

F 

Fatty  degeneration,  anatomical  characters 
of,  92 
from  obstruction  of  coronary  ar- 
teries, 132 
growth  and  degeneration,  90 

anatomical  characters  of,  91 
causes  of,  93 

symptoms  and  effects  of,  94 
physical  signs  and  diagnosis  of, 

99 
treatment  of,  101 
Fevers,  connection  with  pericarditis,  294 
Fingers,  bloodless  in  valvular  lesions,  171 
Fibrin,  remedies  to  promote  coagulation 

of  in  thoracic  aneurisms,  465 
Foramen  ovale,  patent,  235 
Forbes  on  angina  pectoris,  269 
Friction-sounds  in  pericarditis,  316 
mechanism  of,  317 
varieties  of,  317 

morbid  conditions  giving  rise  to,  318 
distinguished  from  endocardial  mur- 
murs, 320 
cardiac  pleural,  323 
Fremitus  in  thoracic  aneurisms,  453 
Fuller  on  pericarditis  in  rheumatism,  291 
on  endocarditis,  378 


G 

Gairdner  on  pericardial  adhesions,  3G3 
Gangrene  of  lung  in  thoracic  aneurisms, 

450 
Gout  in  functional  disorder,  408 
Graves  on  enlargement  of  the  thyroid  body. 

267  ^ 

GrisoUe  on  coagula  within   the  heart  in 
various  diseases,  ^48 
on  polypi  of  heart,  253 
Gutbrod,  theory  of  the  heart's  impulse,  48 


H 

Hallowell  on  rupture  of  heart,  115 
Hoemoptysis  in  hypertrophy,  34 

in  valvular  lesions,  159 
Hemorrhage  from  bowels  in  valvular  le- 
sions, 171 

from  nostrils  in  do.,  171 


30* 


470 


INDEX. 


Heart,  enlargement  of,  17 

normal  dimensions  of,  20 

weight  of,  22 
situation  and  anatomical  relations  of, 

36 
elongation  of  in  the  systole,  47 
physical  signs  of,  40 
apex-beat  of,  normal  situation,  45 
in    enlargement  and   hypertro- 
phy, 49 
additional  impulses   of    in   enlarge- 
ment, 53 
sounds  of,  vide  sounds  of  heart 
lesions  affecting  walls  of,  88 
atrophy  of,  88 

fatty  growth  and  degeneration  of,  90 
softening  of,  106 
induration  of,  111 
aneurism  of,  112 
rupture  of,  115 

in  cardiac  aneurism,  114 
lesions  aflfecting  valves  and  orifices 

of,  118 
congenital  misplacements,  malforma- 
tions, and  defects  of,  vide  malfor- 
mations 
formation  of  coagula  within,  vide  co- 

agula 
polypi  of,  vide  polypi 
inflammatory  affections  of,  282 
functional  disorder  of,  402 
varieties  of,  403 

pathological  relations  and  causa- 
tion of,  405 
symptoms  of,  409 
physical  signs  of,  410 
diagnosis  of,  415 
prognosis  of,  421 
treatment  of,  422 
Heart-sounds,  abnormal  modifications  of 
in  endocarditis,  889 
reduplication  of,  vide  reduplication  of 

heart-sounds 
abnormal   modifications  in    pericar- 
ditis, 325 
in  functional  disorder,  413 
Hemiplegia  in  thoracic  aneurisms,  449 
Hope  on  suffering  from  dyspnoea  in  car- 
diac disease,  174 
on  pericardial  adhesions,  365 
Hypertrophy,     definition     and     different 
forms  of,  18 
anatomical  i;haracters  of,  23 
mode  of  production  of,  25 
from  aortic  lesions,  26 
from  mitral  lesions,  27 
from  tricuspid  and  pulmonic  lesions, 

28 
uncomplicated,  29 
concentric,  31 

symptoms  and  effects  of,  33 
physical  signs  of,  35 
summary  of  physical  signs  of,  71 
treatment  of,  72 


Hypertrophy,     modifications     of     heart- 
sounds  produced  by,  63 
abnormal  movements  of  prsecordia  in, 

67 
diagnosis  of,  70 

of  left  ventricle  from  aortic  contrac- 
tion, 129 
Hydrothorax  in  valvular  lesions,  162 
Hysteria  in  functional    disorder  of   the 
heart,  406 


Impulse  of  heart,  vide  apex-beat 

in  epigastrium  in  health  and  disease, 

54 
shock  produced  by,  in  health  and  dis- 
ease, 56,  411 
heaving  in  hypertrophy,  57 
Impulses   other  than    the    apex-beat  in 
health,  51,  54 
in  enlargement,  52 
in  dilatation,  83 
Inspection  in  enlargement  of  the  heart,  67, 
71 
in  dilatation,  83 
in  pericarditis,  328,  331 
in  pericardial  adhesions,  368 
Induration  of  heart.  111 
Iodine  in  chronic  pericarditis,  355 
Iris,  fatty  degeneration  of,  in  connection 
with  fatty  degeneration  of  the  heart,  98 

K 

Karawagan  on  pericarditis  in  scurvy,  295 
Kennedy  on  pericardial  adhesions,  363 
Kidneys,  granular  degeneration  of,  in  dila- 
tation, 81 
Kirkes  on  fibrinous   deposits  in  arteries 

derived  from  the  heart,  152 
Knapp,  case  of  wound  of  pericardium,  357 
Kyber  on  pericarditis  in  scurvy,  295 


Lancisi  on  venous  pulsation,  145 

Law  on  anaemia  of  brain  in  valvular  le- 
sions, 166 

Lesions  of  valves,  vide  valvular  lesions 
of  aorta,  vide  aortic  lesions 
mitral,  tnde  mitral  lesions 
tricuspid,  vide  tricuspid  lesions 
pulmonic,  vide  pulmonic  lesions 

Liver,  enlargement  of,  in  dilatation,  81 
in  valvular  lesions,  169 
congestion  of,  in  valvular  lesions,  168 
cirrhosis  of,  in  valvular  lesions,  170 

Lividity  of  face  in  valvular  lesions,  174 
in  pericarditis,  302 
in  thoracic  aneurisms,  447 

Louis  on  softening  of  the  heart  in  typhoid 
fever,  106 
on  pericardial  adhesions,  361 


INDEX. 


471 


Lungs,  congestion  of,  in  valvular  lesions, 
154 


M 

Malformations,  congenital,  230,  232 
varieties  of,  238 
diagnosis  of,  236 
causes  of  death  in,  237 
treatment  of,  237 
Maculae  albidte,  289 
Mensuration  in  health,  69 

in  enlargement  of  the  heart,  69,  71,  83 
in  pericarditis,  329,  331 
Mental  condition  in  valvular  lesions,  167 
in  functional  disorder,  403,  407,  417, 

426 
management  of,   in   thoracic    aneu- 
risms, 454 
Mercury  in  treatment  of  valvular  lesions, 
217,  225 
in  acute  pericarditis,  341,  348 
in  endocarditis,  394,  396 
Meigs  on  heart-clot,  246 
Mitral  lesions,  anatomical  characters  of, 
121 
frequency  of,  123 
■water  test  in,  1 23 
effect  on  the  heart-sounds,  207 
diagnostic  characters  of,  210 
Misplacements  of  heart,  231 
Milk  spots,  289 
Mitral  orifice,  size  of,  124 
Morbus  coeruleus,  vide  cyanosis 
Murmur,  cardiac,  in  dilatation,  83 
mitral,  direct  or  diastolic,  186 

regurgitant  or  systolic,  188 
aortic,  direct  or  systolic,  190 

regurgitant  or  diastolic,  191 
intra  ventricular,  202 
hjemic,  202 
dynamic,  203,  412 
in  endocarditis,  387 
in  thoracic  aneurisms,  454 
Murmurs,  endocardial  or  valvular,  177 
different  qualities  of,  179 
differences  of  pitch  in,  179 
musical,  181 

exocardial  or  friction,  178,  316 
organic  and  inorganic,  178,  182,  202, 
412 
classification  of,  185 
endocardial,  abnormal  conditions  giv- 
ing rise  to,  182 
physical  conditions  involved  in, 

182 
dependence  on  valvular  lesions, 

184 
connection  with  obstructive  and 

regurgitant  lesions,  185 
distinguished  from    exocardial, 

320 
pathological  import  of,  200 
produced  -within  aorta,  533 


Murmurs,  systolic  and  diastolic,  186 
localization  of,  194 
diastolic,  localization  of,  197 
inorganic,  distinctive  characters  of, 
202 
Myocarditis,  399 


N 


Nervous  system,  symptoms  referable  to, 
in  acute  pericarditis,  305 
symptoms  referable  to,  in  functional 
disorder  of  the  heart,  406 

Nutrition  in  valvular  lesions,  171* 


0 

(Edema,  pulmonary,  in  valvular  lesions, 

160 
Ogle  on  open  foramen  ovale,  237 
Ormerod  on  pericarditis,  296 
Opium  in  pericarditis,  344,  348,  349 
in  endocarditis,  395,  397 


Palpation  in  enlargement  of  the  heart  and 
hypertrophy,  45,  71 
in  dilatation,  82,  84 
in  fatty  growth  and  degeneration,  99 
in  pericarditis,  326,  330 
in  endocarditis,  386 
in  pericardial  adhesions,  367 
in  functional  disosder  of  the  heart, 

411 
in  thoracic  aneurisms,  450 
Palpitation  in  valvular  lesions,  133 
in  pericarditis,  300 
in  endocarditis,  385 
Paraplegia  in  thoracic  aneurisms,  449 
Paracentesis  of  the  pericardium,  356 
Parry  on  enlargement  of  the  thyroid  body, 

267 
Paralysis  in  valvular  lesions,  165 
Pain  in  valvular  lesions,  133 
in  acute  pericarditis,  298 
in  chronic  pericarditis,  353 
in  endocarditis,  384 
in  thoracic  aneurisms,  448 
Percussion  in  enlargement  of  the  heart  and 
hypertrophy,  35,  40,  70 
to  determine  boundaries  of  superficial 

and  deep  cardiac  regions,  38 
auscultatory,  40 

as  applied  to  discrimination  of  hyper- 
trophy and  dilatation  and  different 
portions  of  the  heart  enlarged,  44 
in  dilatation,  82,  84 
in  fatty  growth  and  degeneration,  99, 

100 
in  pericarditis,  312,  329,  354 
in  pericardial  adhesions,  367 
in  endocarditis,  385 


472 


INDEX. 


Percussion  in  functional  disorder  of  the 
heart,  410 
in  thoracic  aneurisms,  447 
Pennock  and  Moore,  vivisections,  47 
Peacock  on  malformations,  etc.,  of  heart, 

230 
Pericardium,  deficiency  of,  232 

adhesions  of,  289 
Pericarditis  acute,  anatomical  characters 
of,  283 
stages  of,  285 

pathological  relations  and  causa- 
tion of,  290 
,  symptoms  of,  297 

referable  to  heart,  298 
referable  to  circulation,  300 
referable  to  respiratory  sys- 
tem, 303 
referable  to  digestive  sys- 
tem. 304 
referable    to    countenance, 

304 
referable   to   nervous    sys- 
tem, 305 
physical  signs  in,  312 
percussion  in,  312 
auscultation  in,  316 
palpation  in,  328 
inspection  in,  328 
mensuration  in,  329 
summary  of  physical  signs  in, 

329 
prognosis  in,  334 
mode  of  dying  in,  337 
treatment  of,  331 
subacute  and  chronic,  351 

anatomical  characters  of,  351 
physical  signs  of,  354 
treatment  of.  355 
Plethora  in  functional    disorder   of    the 

heart,  405 
Pleuritis  in  valvular  lesions,  162 
in  pericarditis,  293 
in  endocarditis,  380 
Pneumo-pericardium  and  pericarditis,  357 
Pneumonitis  in  valvular  lesions,  162 
in  pericarditis,  293 
in  endocarditis,  380 
formation  of  coagula  •within  the  cavi- 
ties of  the  heart  in,  248 
Portal  congestion  in  valvular  lesions,  168 
Polypi  of  the  heart,  253 
Prjecordia,    enlargement   of,  etc.,  in    en- 

.largement  of  the  heart,  67 
Pressat  on  reduplication  of  heart-sounds, 

276 
Pulse  in  hypertrophy,  38 
in  dilatation,  80 

slo'wness  of  in  fatty  degeneration,  95 
in  valvular  lesions,  135 
in  pericarditis,  301 
irregular  and  intermittent,  137 
jerking,    visible    and   deferred,   140, 
141,  435 


Pulse,  venous,  142 

inequality  in  the  two  wrists  and  loss 
of  in  thoracic  aneurism,  447 
Purring  tremor,  208 
Purring  tremor  in  functional  disorder  of 

the  heart,  411 
Pulmonic  orifice,  normal  size  of,  124 

artery,  obliteration  of,  234 
Purpura  in  pericarditis,  295 
Pulmonic  lesions,  frequency  of,  123 
effect  on  the  heart,  130 
diagnostic  characters  of,  215 

R 

Reid  on  weight  of  heart,  23 
Region,  superficial  cardiac,  36 

deep  cardiac,  37 
Reduplication  of  heart-sounds,  274 

case  observed  by  author,  275 

lesions  connected  with,  276 

mechanism  of,  277 

diagnosis  of,  280 

pathological  import  of,  281 
Respiratory  murmur  in  enlargement,  66 

in  pericarditis,  325 
Respiration,  aberration  of  in  fatty  degene- 
ration, 97 
Revulsives  in  pericarditis,  343,  349,  350 
Rheumatism  in   relation  to  valvular  le- 
sions, 126 

pericarditis  in,  291 

endocarditis  in,  378 
Risus  sardonicus  in  pericarditis,  304 
Richardson  on  the  artificial  production  of 
endocarditis,  375,  381,  395 

S 

Scurvy  in  pericarditis,  295 

Septa,  ventricular  and  auricular  deficiency 

of,  233 
Septum,  supernumerary  in  ventricle,  234 
Seidlitz  on  pericarditis  in  scurvy,  295 
Sedatives  in  acute  pericarditis,  343 
Sibson  on  intensification  of  friction-sounds 
by  pressure,  323 

on  capacity  of  pericardium,  286 

on  diastolic  impulse  in  health,  53 

on  venous  pulse  in  health,  145 
Skoda  on  reinforcement  of  pulmonic  sound, 

207 
Sleep  in  valvular  lesions,  167 
Softening  of  heart,  106 

treatment  of,  110 
Sounds  of  heart  in  health,  58 

mechanism  of,  59 

in  hypertrophy,  63 

in  dilatation,  83 

in  fatty  degeneration,  100 

in  valvular  lesions,  206 

aneurismal,  455 
Sound,  first,  or  systolic,  58 

second,  or  diastolic,  59 


INDEX. 


473 


Spleen,  enlargement  of  in  valvular  lesions, 

171 
Stokes  on  peculiar  aberration  of  respira- 
tion in  fatty  degeneration,  97 
on  softening  of  the  heart,  lOG 
on  enlargement  of  the  thyroid  body, 

267 
on  aifection  of  the  voice  in  thoracic 

aneurisms,  445 
on  auscultatory  signs  in  pneumo-peri- 

carditis,  358 
on  aneurismal  sounds,  455 
Stille  on  cyanosis,  238 
Stimulants  in  pericarditis,  354,  349 
Swett,  case  of  pericarditis  Tvith  large  efiFu- 
sion,  280,  853 
analysis  of  cases  of  thoracic  aneu- 
risms, 442 
Systolic  murmurs,  186,  194 
V  mitral  regurgitant  murmur,  188 

aortic  direct  murmur,  I'dO 


Taylor  on  prominence  of  eyes,  207,  272 
on   pericarditis,   in   connection  with 
pleurisy,  294 
Testa  on  venous  pulse,  145 
Thj^roid  body,  enlargement  of,  267 
cases  observed  by  author,  269 
Thoracic  aneurisms,  vide  aneurisms,  tho- 
racic 
Thurman,  cases  of  cardiac  aneuwsm,  113 
Tinnitus,  414 
Tremor,  purring,  208 
Tricuspid  lesions,  frequency  of,  123 
effect  on  heart,  130 
diagnostical  characters  of,  213 
orifice,  normal  size  of,  124 
regurgitation  in  health  and  disease, 
131 
Tuberculosis  of  lungs  in  connection  with 
pericarditis,  295 
of  heart,  117 


U 

Undvilation,  quasi,  in  dilatation,  83 
in  pericarditis,  329 
in  pericardial  adhesions,  368 

Undefended  space  of  inter-ventricular  sep- 
tum, 233 

Urine  in  valvular  lesions,  172 


Valvular  lesions,  119 

effects  of  on  blood  currents,  121 
pathological    processes    involved    in 

production  of,  124 
relations  to  rheumatism,  126 
symptoms  of,  referable  to  the  heart, 

127 
symptoms  and  pathological  effects  of, 
127 
referable  to  the  circulation,  147 
referable  to  the  respiratory  sys- 
tem, 154 
referable  to  the  nervous  system , 

163 
referable  to  digestion  and  nutri- 
tion, 168 
referable  to  the  genito-urinary 

system,  168 
referable    to    countenance    and 
external  appearance,  174 
physical  signs  of,  176 
determination  of  the  seat  of,  198 
diagnostic  characters  of,  209 
treatment  of,  217 
prognosis  in,  229 
Valves,  deficient  and  in  excess,  285 
Veins,  pulsation  and  turgescence  of,  142 
Venous  hum,  204 
Virchow  on  emboli,  151 
Vocal  resonance  in  prjecordia  as  affected 

by  enlargement  of  the  heart,  66 
Voice,  auscultation  of  in  pericarditis,  325 
in  pericarditis,  304 
in  cases  of  thoracic  aneurisms,  445 
Vomiting  in  pericarditis,  304 

W 

Walshe  on  rupture  of  the  heart,  116 
on  venous  hum,  205 
on  reduplication  of  the  heart-sounds, 
276,  279 
Ward  on  venous  hum,  204 
Weight  of  the  heart,  22 
White  on  external  use  of  diuretics,  227 
White  spots  on  the  heart,  289 
Williams    on   treatment  of  iritis  without 

mercury,  842 
Wood  on  diuretics  in  cardiac  dropsy,  227 
Woillez  on  comparison  of  the  two  sides  of 
the  chest  by  inspection,  67 


THE     END. 


BY  THE  SAME  AUTHOR— (Lately  Issued.) 


PHYSICAL  EXPLORATION 


DIAGNOSIS  OF  DISEASES 


AFFECTING  THE 


RESPIRATORY  ORGANS 

BY  AUSTIN  FLINT,  M.  D., 

Professor  of  Clinical  Medicine,  &c.,  in  the  New  Orleans  School  of  Medicine,  &c. 
In  one  large  and  handsome  octavo  volume ;    extra  cloth,  Three  Dollars. 


Dr.  Flint  is  one  of  the  most  indastrious  and  ener- 
getic men  in  the  medical  profession  of  this  country. 
His  previous  contributions  to  our  medical  literature 
have  won  for  him  both  American  and  European  repu- 
tation, and  we  assure  our  readers  that  the  present 
volume  is  full  of  valuable  and  interesting  matter. 
We  unhesitatingly  commend  the  book  to  all  who  wish 
to  become  well  acquainted  with  thoracic  diseases  and 
the  signs  by  which  they  may  be  distinguished. — N.  W. 
Med.  and  Surg.  Journal,  Nov.  1856. 

We  have  selected  these  points  in  the  physical  ex- 
ploration of  the  chest  not  only  from  their  importance, 
but  to  show  the  manner  in  which  Dr.  Flint  handles 
his  subject.  Our  readers  will,  we  doubt  not,  agree 
with  us  in  the  opinion  that  he  has  done  this  carefully, 
thoroughly,  and  judiciously.  —  Charleston  Medical 
Journal,  Nov.  1856. 

We  can  only  state  our  general  impression  of  the 
high  value  of  this  work,  and  cordially  recommend  it 
to  all.  We  regard  it,  in  point  both  of  arrangement 
and  of  the  marked  ability  of  its  treatment  of  the  sub- 
ject, as  destined  to  take  the  first  rank  in  works  of  this 
class.  So  far  as  our  information  extends,  it  has  at 
present  no  equal.  To  the  practitioner,  as  well  as  the 
student,  it  will  be  invaluable  in  clearing  up  the  diag- 
nosis of  doubtful  cases,  and  in  shedding  light  upon 
difficult  phenomena. — Buffalo  Med.  Journal. 

A  work  of  original  observation  of  the  highest  merit. 
We  recommend  the  treatise  to  every  one  who  wishes 
to  become  a  correct  auscultator.  Based  to  a  very  large 
extent  upon  cases  numerically  examined,  it  carries 
the  evidences  of  careful  study  and  discrimination  upon 
every  page.    It  does.credit  to  the  author,  and,  through 


him,  to  the  profession  in  this  country.  It  is,  what  we 
cannot  call  every  book  upon  auscultation,  a  readable 
book. — Atti.  Journal  Med.  Sciences. 

A  work,  of  which  we  cannot  but  admire  the  spirit 
that  has  presided  over  its  composition.  There  is  an 
evident  accuracy  aimed  at  throughout  by  means  of 
the  carefully  noted  cases,  and  a  searching  after  truth 
which  recommends  the  volume  highly  to  the  attention 
of  the  profession.  On  some  subjects  Dr.  Flint's  sub- 
sequent data  may  lead  him,  perhaps,  to  modify  some 
of  his  observations,  or  to  substitute  for  the  descrip- 
tions of  others  his  own  experience ;  but  the  whole 
character  of  the  work  is  such,  that  it  cannot  fail  to 
raise  him  high  in  the  opinion  of  his  medical  brethren 
as  an  exact  and  most  conscientious  observer. — Med. 
Examiner. 

This  is  the  most  elaborate  work  devoted  exclusively 
to  the  physical  exploration  of  diseases  of  the  lungs, 
with  which  we  are  acquainted  in  the  English  lan- 
guage. From  the  high  standing  of  the  author  as  a 
clinical  teacher,  and  his  known  devotion,  during  many 
years,  to  the  study  of  thoracic  diseases,  much  was  to 
be  expected  fi-om  the  announcement  of  his  determina- 
tion to  embody  in  the  form  of  a  treatise,  the  results 
of  his  study  and  experience.  These  expectations  we 
are  confident  will  not  be  disappointed.  For  our  own 
part,  we  have  been  favorably  impressed  by  a  perusal 
of  the  book,  and  hearti^  recommend  it  to  all  who  are 
desirous  of  acquiring  a  thorough  acquaintance  with 
the  means  of  exploring  the  conditions  of  the  respira- 
tory organs  by  means  of  auscultation  and  percussion. 
— Boston  Med.  and  Surg.  Journal. 


Philadelphia,  BLANCHABD  &  LEA. 


NEW  AND  IMPORTANT  MEDICAL  WORKS. 


J.   C.    DALTON,   JR.,   M.  D., 

Professor  of  Physiology  in  the  College  of  Physicians,  &c.,  New  York. 
A  TREATISE  ON  HUMAN  PHYSIOLOGY,  designed  for  the  use  of  Students  and  Practitioners 
of  Medicine.     "With  two  hundred  and  fifty-four  wood  engravings.     In  one  very  handsome  octavo 
volume,  of  over  600  pages;  extra  cloth,  $4;  leather,  $4  25. 

S.    D.   GROSS,    M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College,  Philadelphia. 
A    SYSTEM    OF    SURGERY,   DIAGNOSTIC,    PATHOLOGICAL,    THERAPEUTICAL,    AND 
OPERATIVE.      With  nine  hundred  and  thirty-six  illustrations.      In  two  very  large  octavo 
volumes,  containing  nearly  2,400  pages,  strongly  bound  ;  $12. 

HENRY   GRAY,  F.  R.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 
ANATOMY,  DESCRIPTIVE  AND  SURGICAL.     The  Drawings  by  H.  V.  Carter,  M.D.,  late 
Demonstrator  of  Anatomy  at  St.  George's  Hospital.     The  Dissections  jointly  by  the  Author 
and  Dr.  Carter.     In  one  very  beautiful  imperial  octavo  volume,  with  three  hundred  and  sixty- 
three  large  and  elaborate  engravings  on  wood  ;  extra  cloth,  $6  25  j  leather,  $7. 

C.    D.    MEIGS,   M.  D., 

Professor  of  Midwifery,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia. 
"WOMAN ;  HER  DISEASES  AND  THEIR  REMEDIES.     A  series  of  Letters  to  his  Class.    Fourth 
and  improved  edition.     In  one  large  octavo  volume,  of  over  700  pages  j  leather,  $3  60. 

S.    H.    DICKSON,   M.  D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 
ELEMENTS  OF  MEDICINE  ;  a  Compendious  View  of  Pathology  and  Therapeutics,  or  the  His- 
tory and  Treatment  of  Diseases.     Second  and  revised  edition.     In  one  large  and  handsome 
octavo  volume,  of  750  pages  ;  leather,  $3  75. 

GEORGE   FOWNES,   PH.D.,   &.C. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and  Practical.  From  the  seventh 
revised  and  corrected  London  edition.  Edited  by  Robert  Bridges,  M.  D.  "With  one  hundred 
and  ninety-seven  illustrations.  In  one  large  royal  12mo.  volume,  of  600  pages,  in  small  type  ; 
leather,  $1  65;  extra  cloth,  $1  50. 

ALFRED   S.   TAYLOR,   M.D.,   F.  R.  S., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital,  &c. 
ON  POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND  MEDICINE.     Second 
American,  from  a  second  revised  and  improved  London  edition.     In  one  large  octavo  volume, 
of  755  pages  ;  leather,  $3  50. 

GOLDING    BIRD,   A.  M.,   M.  D. 

URINARY  DEPOSITS  ;  their  Diagnosis,  Pathology,  and  Therapeutical  Indications.  Edited  by 
Edmund  Lloyd  Birkett,  M.  D.  A  new  American,  from  the  fifth  and  enlarged  London  edition. 
In  one  neat  octavo  volume,  of  about  400  pages ;  extra  cloth,  $2. 


ALFRED    STILLE,   M.  D. 

THERAPEUTICS  AND  MATERIA  MEDICA ;  A  Systematic  Treatise  on  the  History,  Descrip- 
tion, Actions,  and  Uses  of  Medicinal  Agents.  In  two  large  and  handsome  octavo  volumes,  of 
over  1,500  pages. 

FRANK   H.    HAMILTON,    M.D., 

Professor  of  Surgery  in  the  Buffalo  Medical  College,  &c. 
A  COMPLETE  PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.      In  one 
very  handsome  octavo  volume,  with  about  two  hundred  and  fifty  illustrations. 

EDWARD   PARRISH, 

Lecturer  on  Practical  Pharmacy,  &c.,  in  the  Philadelphia  Academy  of  Medicine. 
AN  INTRODUCTION  TO  PRACTICAL  PHARMACY,  designed  as  a  Text-book  for  the  Student, 
and  as  a  guide  for  the  Physician  and  Pharmaceutist.     "With  many  FormulEC  and  Prescriptions. 
Second  edition,  thoroughly  revised  and  extensively  enlarged  and  improved.     In  one  large  and 
handsome  octavo  volume,  with  several  hundred  illustrations. 

HENRY   BENNET,   M.D. 
A  PRACTICAL  TREATISE  ON  INFLAMMATION  OF  THE  UTERUS,  its  Cervix  and  Append- 
ages ;  and  on  its  connection  with  Uterine  Disease.     New  and  much  enlarged  edition.     In  one 
octavo  volume. 

Philadelphia,  BLANCHARD  &  LEA. 


BLANCHARD  &  LEA'S 
MEDICAL  AND  SURGICAL  PUBLICATIOIfS. 

u  

TO  THE  MEDICAL  PROFESSION. 

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For  the  present,  therefore,  the  prices  on  this  Catalogue  are  those  at  which  our 
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I^IIILADELPHIA,  July,  IStil. 

***  We  have  recently  issued  an  Illustrated  Catalogue  of  Medical  and  Sci- 
entific Publications,  forming  an  octavo  pamphlet  of  80  large  pages,  containing 
specimens  of  illustrations,  notices  of  the  medical  press,  &c.  &e.  It  has  been  pre- 
pared without  regard  to  expense,  and  will  be  found,  one  of  the  handsomest  speci- 
mens of  typographical  execution  as  yet  presented  in  this  country.  Copies  will  be 
sent  to  any  address,  by  mail,  free  of  postage,  on  receipt  of  nine  cents  in  stamps. 

Catalogues  of  our  numerous  publications  in  miscellaneous  and  educational  litera- 
ture forwarded  on  application. 

J^°  The  attention  of  physicians  is  especially  solicited  to  the  following  important  new  works 
aud  new  editions,  just  issued  or  nearly  ready  : — 

Bowman's  Medical  Chemistry,  a  new  ecilion, Seepage        4 

Bowman's  Practical  Chemistry,  a  new  edition, •  "  4 

Bennett  on  the  Uterus,  sixth  edition, "  4 

Bumstead  on  Venereal,  second  edition, "  5 

Barclay  on  Medical  Diagnosis,  third  edition, "  5 

Brande  and  Taylor's  Chemistry, " .  "  ti 

Dalton's  Human  Physiology,  3d  edition, "  H 

Dunglison's  Medical  Uiciioiiary,  a  ruvised  edition, "     .       12 

Ellis' Formulary,  new  edition, '«  13 

Enchsen's  System  of  Surgery,  a  revised  edition, «'  14 

Flint  on  the  Heart, «  14 

Gross's  System  of  Surgery,  second  edition, "  Itj 

Gray's  Anatomy,  Descriptive  and  Surgical,  2d  edition,        .        .         .        ,  "  17 

Hamilton  on  Fractures  and  Dislocations,  second  edition,      .        .        .        .  "  18 

Hodge's  Obstetrics, "  la 

IVTeigs'  Ob.-tetrics,  fourth  edition, "  ai 

Parrish's  Practical  Pharmacy,  a  new  edition,      ......  "  a** 

Stille's  Therapeutics  and  Materia  Medica, "  27 

Simpson  on  Diseases  of  Women, "  27 

Salter  on  Asthma, «  27 

Slade  on  Diphtheria,  new  edition <«  27 

Sargent's  Minor  Surgery,  new  edition, "  28 

Watson's  Practice  ol  Pliysic, "  30 

Wilson  on  Ihe  Skin,  fiuh  edition, "  31 


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being  a  very  full  and  complete  abstract,  methodically  arranged,  of  the 

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The  Work  seleclerl  lor  the  year  lStJ4,  commencing  in  the  number  for  January,  is 

COiXSUMPTION;  ITS  EARLY  AND  REMEDIABLE  STAGES. 

BY  EDWARD  SMITH,  M.  D., 

Assistant  Phyj^ician  to  the  Bromptou  Cousumptiou  Hospital,  &c. 
The  special  experience  of  ihe  author  in  the  treatment  of  this  disease  invests  his  work  with  a 
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of  their  own  postage  on  the  receipt  of  each  number.  The  advantage  of  a  remittance  when  order- 
ing the  Journal  will  thus  be  apparent. 

Kemittances  ul  -ubscriptions  can  be  mailed  at  our  risk,  when  a  certificate  is  taken  from  the  Post- 
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,  Address  BLANCHARD  &  LEA,  Philadelphia. 


''AND    SCIENTIFIC    PUBLICATIONS. 


ASHTON   (T.  J.), 

Surgeon  to  the  Blenheim  Dispensary,  &c. 

ON  THE   DISEASES,  INJURIES,  AND   MALFORMATIONS   OF   THE 

RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.     From  the  third  and  enlarged 
London  edition      With  handsome  illustrations.    In  one  very  beautifully  printed  octavo  volume, 


of  about  300  pages,  extra  cloth.     $2  50 

The  most  complete  one  we  possess  on  the  subject. 
Medico- Ckirurgical  Revieto. 

We  are  satisfied,  after  a  careful  examination  of 
the  volume,  anU  a  comparison  of  its  coutents  witil 
those  of  its  leading  preilecessors  and  contemporaries, 
that  the  best  way  for  the  reader  to  avail  himself  of 


the  excellent  advice  given  in  the  concluding  para- 
graph above,  would  be  to  provide  himself  with  a 
c  )py  of  the  book  from  which  it  has  been  taken,  and 
diligently  to  con  its  inscructive  pages.  They  may 
secure  to  him  m  iny  a  triumphand  fervent  blessing. — 
Am.  Journal  Med.  Sciences. 


ALLEN    (J.    M.),    M.  D., 
Professor  of  Anatomy  in  the  Pennsylvania  Medical  College,  &c. 

THE  PRACTICAL  ANATOMIST;  or,  The  Studeat's  Guide  iu  the  Dissecting. 

ROOM.     With  266  illustrations.   In  one  handsome  royal  12mo.  volume,  of  over  600  oag-es  extra 


cloth.     $2  25 

We  believe  it  to  be  one  of  the  most  useful  works 
upon  the  subject  ever  written.  It  is  handsomely 
illustrated,  well  printed,  and  will  be  found  of  con- 
venient size  for  use  in  the  dissecting-room. — Med. 
Mxnminer. 

However  valuable  may  be  the  "Dissector's 
Guides"  which  we,  of  late,  have  had  occasion  to 


notice,  we  feel  confident  that  the  work  of  Dr.  Allen 
IS  superior  to  any  of  them.  We  believe  with  the 
author,  that  none  is  so  fully  illustrated  as  this,  and 
Che  arrangement  of  the  work  is  such  as  to  facilitaio 
the  labors  of  the  student.  We  most  cordiiUy  re- 
commend it  to  their  attention. —  Western  Lanoet. 


ANATOMICAL   ATLAS. 
By  Professors  H.  H.  Smith  and  W.  E.  Horner,  of  the  University  of  Pennsyl- 
vania.   1  vol.  8vo.,  extra  cloth,  with  nearly  650  illustrations.    |S^  See  Smith,  p.  26. 

ABEL   (F.   A.),    F.  C.  S.    AND    C.    L.    BLOXAM. 
HANDBOOK  OF  CHEMISTRY,  Theoretical,  Practical,  and  Technical;  with  a 

Recommendatory  Preface  by  Ur.  Hofmann.    In  one  large  octavo  volume,  extra  cloth,  of  663 
pages,  with  illustrations.    $4  00. 

ASHWELL   (SAMUEL),   M.D., 

Obstetric  Physician  and  Lecturer  to  Guy's  Hospital,  London. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  PECULIAR  TO  WOMEN. 

Illustrated  by  Cases  derived  from  Hospital  and  Private  Practice.  Third  American,  from  the  Third 
and  revised  London  edition.     In  one  octavo  volume,  extra  cloth,  of  528  pages.     $3  00. 
The  most  useful  practical  work  on  the  subjecfrin  I      The  most  able,  and  certainly  the  most  standard 
the  English  language.  —  Boston  Med.  and  .Swrg-.     and  practical,  work  on  female  diseases  that  we  liav« 
Journal.  |  yet  seen. — Medico-Chirurgical  Review. 


ARNOTT   (NEILL),  M.D. 
ELEMENTS    OP    PHYSICS;    or  Natural  Philosophy,  General  and  Medical. 

Written  tor  universal  use,  in  plain  or  non-technical  language.  A  new  edition,  by  Isaac  Kays 
M.  D.  Complete  in  one  octavo  volume,  leather,  of  484  pages,  with  about  two  hundred  iiiustra 
tions.     $2  50. 

BIRD  (GOLDING),  A.  M.,  M.  D.,  Ac. 
URINARY     DEPOSITS:     THEIR     DIAGNOSIS,    PATHOLOGY,    AND 

THEllAPEUTICAL  INDICATIONS.  Edited  by  Edmund  Lloyd  Birkett,  M.  D.  A  new 
American,  from  the  last  and  enhirged  London  edition.  With  eighty  illustrations  on  wood.  In  one 
handsome  octavo  volume,  of  about  400  pages,  extra  cloth.     $3  00. 

It  can  scarcely  be  necessary  for  us  to  say  anything  i  to  the  extension  and  satisfactory  employment  of  our 
of  tue  merits  of  this  well-known  Treatise,  which  so  therapeutic  resources.  In  the  preparation  of  thia 
adaiirably  brings  into  practical  application  the  re-  new  edition  of  his  work,  it  is  obvious  that  Dr.  Gold- 
Bults  of  those  microscopical  and  chemical  re-  I  ing  Bird  has  spared  no  pains  to  render  it  a  faunful 
searches  regarding  the  physiology  and  pathology  j  representation  of  the  present  stale  of  seienc.fie 
of  the  urinary  secretion,  which  haveoonlribuceU  so  knowledge  on  the  suDject  it  embraces. — British. and 
much  to  the  increase  of  our  diagnostic  powers,  and  |  Foreign  Med.-Chir.  Review. 


BENNETT   (J.    HUGHES),    M.D.,    F.  R.  S.  E., 

Professor  of  Clinical  Medicine  in  the  University  of  Edinburgh,  &c. 

THE  PATHOLOGY  AND  TREATMENT  OP  PULMOxXARY  TUBERCU- 

LOSIS,  and  on  the  Local  Medication  of  Pharyngeal  and  Laryngeal  Diseases  frequently  mistaken 
for  or  associated  with,  Phthisis.     One  vol.  8vo.,extra  cloth,  with  wood-cuts.    pp.  130.     $1  25. 

BARLOW   (GEORGE  H.),   M .  D. 

Physician  to  Guy's  Hospital,  London,  &c. 

A  MANUAL  OF  THE  PRACTICE  OP  MEDICINE.    With  Additions  by  D. 

F.  CoNDiE,  JM.  D.,  author  of"  A  Practical  Treatise  on  Diseases  of  Children,"  &c.    la  one  haad- 

somp'  notnvn  v<^liimt»    f>Ytrn  cloth.  of  over  fiOO  nas'es.      $2  7,5. 


some  octavo  volume,  extra  cloth,  of  over  600  pages.     $2  75. 

We  recommend  Dr.  Harlow's  Manual  in  the  warm- 
est manner  as  a  most  valuable  vade-mecum.  VVe 
liave  had  frequent  occasion  to  consult  it,  and  have 


found  it  clear,  concise,  practical,  and  sound Bos- 
ton Med.  and  Surg.  Journal. 


BLANCHARD   &    LEA'S    MEDICAL 


BUDD  (GEORGE)    M.D.,F.R.S,., 

Professor  of  Medicine  in  King's  College,  London. 

ON   DISEASES   OF   THE   LIVER.      Third   American,  from   the   third   and 

enlarged  London  edition.     In  one  very  handsome  octavo  volume,  extra  cloth,  with  four  beauti- 
fully colored  plates,  and  numerous  wood-cuts.     pp.  500.     $.3  50 


Has  fairly  eBfablisheil  for  itself  a  place  among  tl^e 
classical  medical  literature  of  England. — British 
and  Foreign  Medico-Chir.  Review. 

Dr.  Budd's  Treatise  on  Diseases  of  the  Liver  is 
now  a  standard  work  in  Medical  literature,  and  dur 
ing  the  intervals  which  have  ela|)Bed  between  the 
euceessive  editions,  the  author  has  incorporated  into 


the  text  the  mo?t  striking  novelties  which  have  cha- 
racterized the  recent  progress  of  hepatic  physiology 
ind  pathr)logv  :  so  thatalthouRh  the  siyp  of  the  hook 
is  not  perceptibly  changed,  the  liistory  of  liver  dis- 
eases is  made  more  complete,  and  is  kept  upon  a  level 
with  the  progress'of  modern  science.  It  is  the  best 
work  on  Diseases  of  the  Liver  in  any  language. — 
London  Med.  Times  and  Gazette. 


BUCKNILL  (J.  C),   M.  D.,  and        DANIEL   H,   TUKE,    M.  D., 

Medical  Superintendent  of  the  Devon  Lunatic  Asylum.        Visiting  Medical  Officer  to  the  York  Retreat. 

A  MANUAL  OF   PSYCHOLOaiGAL   MEDICINE;   containing  the  History, 

Not^ology,  Det^cription,  Statistics,  Diagnosis,  Pathology,  and  Treatment  of  INSANITY.  With 
a  Plate.  In  one  handsome  octavo  volume,  of  536  pages,  extra  cloih.  $3  50. 
The  increase  ot  menial  disease  in  its  various  lorms,  and  the  diriicult  questions  to  which  it  ia 
constantly  giving  rise,  render  the  subject  one  of  daily  enhanced  interest,  requiring  on  the  part  of 
the  physician  a  constantly  greater  familiarity  with  this,  the  most  perplexing  branch  of  his  profes- 
sion. Yet  until  the  appearance  of  the  present  volume  there  has  been  for  some  years  no  work  ac- 
cessible in  this  country,  pre>enting  the  results  of  recent  invesiigaiionp  in  the  Diagnosis  and  Prog- 
nosis of  ln>anity,  and  the  greatly  improved  methods  of  ireatmeiii  which  have  done  so  much  in 
alleviating  the  condition  or  restoring  the  health  of  the  insane. 

BENNETT   (HENRY),  M.  D. 
A  PRACTICAL   TREATISE    ON   INFLAMMATION  OF  THE  UTERUS, 

ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Disease.  Sixth 
American,  from  the  fourili  and  revised  English  edition.  In  one  octavo  volume,  of  about  500 
pages,  extra  cloth.  $3  50.     (Just  Ready.) 

BROWN    (ISAAC    BAKER), 

Surgeon- Accoucheur  to  St.  Mary's  Hospital,  tec. 

ON  SOME  DISEASES  OF  WOMEN  ADMITTING  OF  SURGICAL  TREAT- 

MENT.     With  handsome  illustrations.     One  vol.  8vo.,  extra  cloth,  pp.  276.     $1  60. 

and  merit  the  careful  attention  of  every  surgeon- 
accoucheur. — Association  Journal. 

We  have  no  hesitation  in  recommending  this  book 
to  tlie  CHreful  attention  of  all  surgeims  who  make 
fenjale  cumplHinis  a  part  of  their  study  and  practice. 
— Dublin  (.quarterly  Journal. 


Mr.  Brown  has  earned  for  himself  a  high  reputa- 
tion in  the  operative  treatment  of  sundry  diseases 
and  injuries  to  which  females  are  peculiarly  subject. 
We  can  truly  say  of  his  work  that  it  is  an  important 
addition  to  obstetrical  literature.  The  operative 
BU''gesti(ms  and  contrivances  which  Mr.  Brown  de- 
BCnbes,  exhibit  much  practical  sagacity  and  skill, 


BOWMAN  (JOHN    EJ,  M.D. 
PRACTICAL   HANDBOOK   OF    MEDICAL    CHEMISTRY.    Edited  by  C. 

L  Bloxam.    Third  American,  from  the  fourth  and  revised  English  Edition     In  one  neat  volume, 
royal  I'-imo.,  extra  cloth  with  numerous  illustrations    pp.351.  §175.  {Now  Ready,  M&s  ASQZ.) 


Of  this  well-known  handbook  we  may  say  that 
it  retains  all  iis  <  Id  simplicity  and  clearness  of  ai- 
rangemeiit  and  description,  whilst  it  has  received 
fcom  the  able  edit -r  those  finishing  louches  which 
the  progress  of  chemistr\  has  lendi  red  necessary  — 
London  Med.  Times  and  Gazette,  Nov  29,  It62. 

Not  is  anything  huiriedover,  anything  shirked  ; 
open  the  book  where  you  will,  you  find  the  same 
careful  treatmentof  the  subject  manifested,  anj  the 
beat  process  for  the  atlaiiiment  of  the  particular  ob- 


ject in  view  lucidly  detailed  and  explained.  And 
this  new  edition  is  not  merely  a  reprint  of  the  lust. 
Wuh  a  laudable  desire  to  keep  the  book  up  to  tne 
scientific  mark  of  the  present  age,  every  im|)rove- 
iiient  in  analytical  method  has  been  iu'roduced.  In 
conclusion,  we  would  only  say  that,  familiar  from 
long  acquaintiince  witn  each  p;ige  of  th<  former 
issues  ot  iliis  lirtle  book,  we  gladly  place  beside 
them  another  presenting  so  many  acceptable  im- 
provements and  additions. — Dublin  Medical  Press. 


BY  THE  SAME  AUTHOH. 

INTRODUCTION    TO    PRACTICAL    CHEMISTRY,    INCLUDING    ANA- 

LYSIS.  Third  American,  from  the  third  and  revised  London  edition.  With  numerous  illus- 
trations In  one  neat  vol.,  royal  12mo..  extra  cloth  SI  75  (Just  Ready.) 
This  favorite  litt'e  manual  has  received  a  very  thorough  and  caretui  revi-ion  at  the  hands  of  a 
competent  editor,  and  will  be  found  fully  brought  up  to  the  present  condition  ot  ehemiial  science. 
Many  portions  have  been  rewritten,  the  subjects  of  the  blow-pipe  ui.d  vulumelric  aiKily>i-i  have  re- 
ceived special  attention,  and  an  additional  chapler  has  been  appended  Siudenis  ol  piacaical  thcm- 
istry  will  therefore  find  it,  as  herciolore,  a  mos-t  convenient  Mid  condensed  lext-booK  and  guide  m 
the  operations  of  the  laboratory. 

BUCKLER  ON  THE  KTIOLOGY, PATHOLOGY, 
AND  TREATMENT  OF  FIBRO-BRUNCHI- 
TIS  AND  RHEUMATIC  PNEUftlONlA  In 
one  Hvo.  voluiiie,  extra  cU)th.     pp.150,     fil  25. 

BLOOD  AND  URINE  (MANUALS  ON).  BY 
JOHN  WILLIAM  GRIFFITH,  G.  OWEN 
REESE,  AND  ALFRED  MaRKWICK.  One 
thick  volume,  rt>yal  12ino.,  extra  cloth,  with 
plates      pp.  160.     SI  25. 

BROUIE'S  CLINICAL  LECTURES  ON  SUR- 
GERY.    Ivol.bvo.  cloth.    350pp.    912S. 


BEALE  ON  THE  LAWS  OF  HEALTH  IN  RE- 
LATION TO  MIND  AND  BODY.  A  Series  of 
Letters  from  an  old  Practitioner  to  a  Patient.  In 
one  volume,  royal  12mo.,  extra  cloth,  pp.  296. 
60  cents. 

BUSHNAN'S  PHYSIOLOGY  OF  ANIMAL  AND 
VEGETABLE  LIFE;  a  Popular  Treatise  on  the 
Functions  and  Phenomena  of  Organic  Lile.  In 
one  handsome  royal  l2nio.  volume,  extra  cloth, 
with  over  100  illustrations,    pp.  234.    80  cents. 


AND    SCIENTIFIC    PUBLICATIONS. 


BUMSTEAD  (FREEMAN   J.)  M.  D., 
Lecturer  on  Venereal  Diseases  at  the  College  of  Piiysicians  and  Surgeons,  New  York,  &c. 

THE    PATHOLOGY    AiND   TREATMENT   OF    VENEREAL   DISEASES, 

inclnding;  the  rej^ull:*  of  recent  invesi igaiions  upon  the  subject.  Second  edition,  thoroughly  re- 
vistd  piid  tiiuch  imp'ovf  d.  With  illii>iiations  on  wood.  In  one  very  handsome  octavo  volume, 
ot  about  700  pages.     $4  50     {Not/.'  Rcarty.) 


By  far  the  most  valuable  contribution  to  this  par- 
ticular branch  of  p-ractice  that  has  seen  the  light 
v/ithin  the  last  score  of  years.  His  clear  !>nit  accu- 
rate descriptions  oC  the  various  forms  of  venereal 
disease,  and  especially  the  methods  of  treatment  he 
proposes,  are  worthy  of  the  highest  encoiriium.  In 
these  respects  it  is  better  adapted  for  the  assistance 
of  the  every-day  practitioner  than  any  Other  with 
which  we  are  acquainted.  In  variety  of  methods 
proposed,  in  minuteness  of  direction,  guided  by  care- 
lul  diacrimination  of  varying  forms  and  compliea 
tions,  we  write  down  the  book  as  uuaurpasstd.  It 
is  a  work  which  shonld  be  in  the  possesbii  n  of  every 
practitioner.— CA?cag-o  Med,  Journal,  Nov.  1861. 

Tiie  foregoing  admirable  volume  comes  to  us,  em- 
bracing the  whole  subject  of  syphilology,  resolving 
many  a  doubt,  correeiiiig  and  confirming  many  an 
entertained  opinion,  and  in  our  estimation  the  best, 
Completest,  fullest  monogi  iiph  on  this  subject  in  our 
language.  As  far  as  the  author's  labors  tliemselves 
are  concerned,  we  feel  it  a  duty  to  say  tiiat  he  has 
not  only  exhausted  his  subject,  but  he  has  presented 
to  us,  without  the  slightest  hyperbiile,  the  best  di- 

fested  treatise  on  these  diseases  in'  our  language 
le  has  carried  its  literaturt  dowrn  to  the  prea.  nt 
moment,  and  has  achieved  his  task  in  a  manner 
which  cannot  but  redound  to  his  credit. — British 
Am''rican  Journal,,  Oct.  1S6I. 

We  believe  this  treatise  will  come  to  be  regarded 
as  high  authority  in  this  branch  of  medic»l  practice, 
and  we  cordially  commend  it  to  the  favorable  notice 
of  our  brethren  in  the  profession.  For  (mr  own  part, 
we  candidly  confess  that  we  have  received  nany 
new  ideas  from  its  perusal,  as  well  as  modified  many 
views  which  we  have  long,  and,  as  we  now  think. 
erroneouBly  entertained  on  the  subject  of  syphilis. 


To  sum  up  all  in  a  few  words,  this  book  is  one  which 
no  practising  physician  or  medical  student  can  verv 
wtll      ""      ■  ■  ■  ------ 


Nov. 


utTord  to  do  without. — Americarf.  Med    Times, 
2,  1861.  •         . 

The  wh.ile  work  presents  a  oorriplete  history  of 
venereal  diseases,  comprising  mu  'h  interesting  and 
yalual)ie  material  that  has  been  spread  through  mi  d- 
ical  ](mrnals  within  the  last  twt-nty  years — the  pe- 
riod of  many  experiments  and  investigations  on  the 
subject— the  whle  carefully  digested  hythe«id<)f 
the  author's  extensive  personal  experience,  and 
offeied  to  tne  profession  in  an  admirable  form  Its 
eompletpnrss  is  secured  by  good  plates,  which  are 
especially  full  in  the  anatomy  of  the  genital  orgnns 
We  have  examined  it  with  great  satisi'nction,  and 
congratulate  the  medical  profession  in  America  on 
the  nationality  of  a  work  ihat  miy  fairly  be  jailed 
original. — Be.rkskire  Med.  Journal,  Dec    1^61. 

One  thing,  however,  we  are  impelled  to  say,  that 
we  have  met  with  no  other  book  on  syphilis,  in  the 
Eng  ish  language,  which  gave  so  full,  clear  and 
imj)artial  views  of  the  important  subjr  cts  on  wiiijh 
It  treats.  We  cannot,  however,  ref^rain  from  ex- 
pressing our  satist'action  with  the  full  and  pers  licu- 
ous  m;inner  in  which  the  subject  has  been  presented, 
and  the  careful  atlention  to  minute  details,  so  use- 
ful— not  to  say  indispensable — in  a  practic:il  i  reatise. 
In  conclusion,  if  we  may  be  pardcuied  the  use  of  a 
phrase  now  become  stereotyped,  but  which  we  here 
employ  in  all  seriousness  and  s'lictrity,  we  do  not 
hesitate  to  express  t.ie  opinion  that  Dr.  Bumstead's 
Treatise  on  Venereal  Diseases  is  a  ''  work  without 
which  no  medical  library  will  hpreafter  be  cemsi- 
dered  complete." — Boston  Med.  and  Surg.  Journal, 
Sept.  5,  1861. 


BARCLAY  (A.  W,),  M.  D., 

Assistant  Physician  to  St.  George's  Hospital,  Sec. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS;    being  an  Analysis  of  the  Signs 

and  Symptoms  of  Disease.  Th'rd  American  from  the  second  and  revised  London  edition.  In 
one  neat  octavo  volume,  extra  cloth,  ol  451  pages.  $3  25  iJ ust  Ready .) 
The  demand  for  a  second  edition  of  this  work  shows  that  the  vacancy  which  it  attempts  to  sup- 
ply has  been  recogriized  by  the  profession,  and  that  the  etiijrts  of  the  author  to  meet  the  want  have 
been  successful.  The  revision  which  it  has  enjoyed  will  render  it  belter  adapted  than  betore  to 
afford  assistance  to  the  learner  in  the  prosecution  of  his  studies,  and  to  tht  practitioner  who  requires 
a  convenient  and  accessible  manual  tor  speedy  reference  in  the  exigencies  of  his  daily  duties.  For 
this  latter  purpose  its  complete  and  extensive  Index  renders  it  especially  valuable,  offering- facilities 
for  immediately  turning  to  any  class  of  symptoms,  or  any  variety  of  di.sease. 

The  task  of  composing  such  a  work  is  neither  an 
easy  nor  a  light  (me ;  but  Dr.  Barclay  has  performed 
it  in  a  manner  which  meets  our  most  unqualified 
approbation.  He  is  no  mere  theorist;  he  knows  his 
work  thoroughly,  and  in  attempting  to  perform  it, 
has  not  exceeded  his  powers. — British  Med.  Journal . 

We  venture  to  predict  that  the  work  will  be  de- 
servedly popular,  and  soon  become,  like  Watstm'f 
Practice,  an  indispensable  necessity  to  the  practi- 
tioner.— iV.  A.  Med.  Journal. 

An  inestimable  work  of  reference  for  the  young 
practitioner  and  student. — Nashville  Med.  Journal. 


We  hope  the  volume  will  have  an  extensive  cir- 
culation, not  among  students  of  medicine  only,  but 
practitioners  also.  They  will  never  regret  a  faith- 
ful study  of  its  pages. —  Cincinnati  Lancet. 

An  important  acquisition  to  medical  literiture. 
It  IS  a  work  of  high  merit  both  irum  the  vast  im- 
por  ance  of  the  subject  upon  wliich  it  treats,  and 
also  iTom  the  real  auility  displayed  in  "fn  elabora- 
tion. In  conclusion,  let  us  Dfspeak  for  tn:s  voluioe 
that  attention  of  every  student  of  our  art  which  it 
so  richly  deserves  -  that  place  in  evirry  meuical 
library  which  it  can  so  well  aaoru.-  Peninsular 
Medicil  fouriial. 


BARTLETT  (EI.ISHA),  M.  D. 

THE   HISTORY,  DIAGNOSIS,  AND  TREATxMENT  OF  THE  FEVERS 

OF  THE  UNITED  STATES.     A  new  and  revised  edition.     By  Alonzo  Clark    M.  D.,  Prof. 

of  Pathology  and  Practical  Medicine  in  the  N.  Y.  College  of  Physicians  and  Surgeons,  &c.     in 

one  octavo  volume,  of  six  hundred  pages,  extra  cloth.    Price  $3  75 

It  is  a  work  of  great  practical  value  and  interest, 
containing  much  that  is  new  relative  to  the  several 
diseases  of  which  it  treats,  and,  with  the  additions 
of  the  editor,  is  fully  up  to  the  tunes.  The  distinct- 
ive features  of  the  different  forms  of  fever  are  phi  inly 


and  forcibly  portrayed,  and  the  linesof  demarcation 
carefully  and  accurately  drawn,  and  to  the  Ameri- 
can practitioner  is  a  more  valuable  and  safe  guide 
than  any  worlj  on  fever  extant. — Ohio  Med.  and 
Surg  Journal. 
This  excellent  monograph  on  febrile  disease,  has 


stood  deservedly  high  since  its  first  publication.  It 
will  be  seen  that  it  has  now  reached  its  fimrth  edi- 
tion under  the  supervision  of  Prof  A.  (JIarK,  a  ijen- 
tleinan  who,  from  the  nature  of  his  studies  and  pur- 
suits, is  well  Calculated  to  api)reciate  and  discuss 
r.he  many  intricate  and  difficult  questions  in  patho- 
logy. His  annotati(ms  auii  much  to  die  intcresi  o( 
the  work,  and  have  brought  It  well  up  to  the  condi- 
tion of  the  science  as  it  exists  .it  tlie  present  ilay 
in  regard  to  this  class  of  diseases. — Southern  SStd. 
and  Surg.  Journal. 


BLANCHARD  &  LEA'S    MEDICAL 


BRANDS  (WM.  T.)  D.C.  L. 
Of  her  Majesty's  Mint,  &.c. 


ASD  ALFRED  S.  TAYLOR,  M.  D.,  F.  R'.  S. 

Professor  of  Chemistry  and  Medical  Jurisprudence  in 
Guy's  Hospital. 

CHEMISTRY.     In  one  handsome  8vo.  volume  of  696  pages,  extra  doth.    $4  00. 

{Now  Ready,  May,  1863  ) 

"  Ilaviiig  been  engaged  in  teaching  Chemistry  in  this  Metropolis,  the  one  for  a  period  of  forty, 
and  the  oilier  for  a  period  ol  thirty  yeart;,  ii  ha>  appeared  to  us  that,  in  spite  of  the  number  of  hooks 
already  exi>tii)g,  there  was  room  for  an  additional  volume,  which  s-hi  uld  be  e>pecially  adap'ed  (or 
the  u>e  of  studeijts.  'In  preparing  such  a  volume  lor  the  press,  we  have  endeavored  to  bear  ia 
mind,  Ihat  the  student  in  the  present  day  lias  much  to  Itarn,  and  but  a  short  time  at  his  disposal  lor 
the  ac'()ni!-itioi!  ofihis  learning." — Authoks'  Preface. 

In  reprinting  this  volume,  1L^  passage  through  the  press  has  been  superintended  by  a  competent 
chemist,  who  has  sedulously  endeavored  to  secure  the  accuracy  so  neces>ary  in  a  work  of  this 
nature.  No  notes  or  additions  have  been  introduced,  but  the  publishers  have  been  favored  by  the 
authors  with  some  corrections  and  revit-ions  of  the  first  twenty-one  chapters,  which  have  been  duly 
inserted. 

In  so  progressive  a  science  as  Chemistry,  the  latest  work  always  has  the  advantage  of  presenting 
the  subject  a>  modified  by  the  results  of*tbe  laiCbt  investigations  and  discoveries.  That  this  advan- 
tage has  been  made  the  most  of,  and  that  the  work  possesses  superior  attractions  arising  from  its 
clearness,  simplicity  of  style,  and  lucid  arrangement,  are  manifested  by  the  unanimous  testimony 
of  the  English  medical  press. 


It  needs  no  great  sagacity  to  foretell  that  this  boob 
■will  be,  literally,  the  Handbook  in  Chemistry  of  the 
student  and  practitioner.  For  clearness  of  language, 
accuracy  of  description,  extent  of  information,  and 
freedom  from  pedantry  and  mysticism  of  modern 
chemistry,  no  other  text-book  comes  into  competition 
with  it.  The  result  is  a  work  which  for  fulness  of 
matter,  for  lucidity  of  arrangement,  for  clearness  of 
style.  Is  as  yet  without  a  rival.  And  long  will  it  be 
•without  a  rival.  For,  although  with  the  necessary 
advance  of  chemical  knowledge  addenda  will  be  re- 
quired, there  will  be  little  to  take  away.  The  funda- 
mental excellences  of  the  book  will  remain,  preserv- 
ing it  for  years  to  come,  what  it  now  is,  the  best  guide 
to  the  study  of  Chemistry  yet  given  to  the  world. — 
Londmi  Lancet,  Dec.  20,  18(32. 

Most  assuredly,  time  has  not  abated  one  whit  of  the 
fluency,  the  vigor,  and  the  clearness  with  which  they 
not  only  have  composed  the  work  before  us,  but  have, 
so  to  say,  cleared  the  ground  for  it,  by  hitting  right 


and  left  at  the  affectation,  mysticism,  and  obscurity 
which  pervade  some  late  chemical  treatises.  Thus 
conceived,  and  worked  out  in  the  most  sturdy,  com- 
mon sense  method,  this  book  gives,  in  the  clearest  and 
most  summary  method  possible,  all  the  facts  and  doc- 
trines of  chemistry,  with  more  especial  reference  to 
the  wants  of  the  medical  student. — London  Medical 
Times  and  Gazette,  Nov.  29,  1S62. 

If  we  are  not  very  much  mistaken,  this  book  will 
occupy  a  place  which  none  has  hitherto  held  among 
chemists;  for,  by  avoiding  the  errors  of  previous  au- 
thors, we  have  a  work  which,  for  its  size,  is  certainly 
the  most  perfect  of  any  in  the  English  language. 
There  are  several  points  to  be  noted  in  this  volume 
which  separate  it  widely  from  any  of  its  tfompeers^ 
its  wide  application,  not  to  the  medical  student  only, 
nor  to  the  student  in  chemistry  merely,  but  to  every 
branch  of  science,  art,  or  commerce  which  is  in  auy 
way  connected  with  the  domain  of  chemistry. — Lor^ 
donMed.  Review,  Feb.  ISGo. 


BARWELL  (RICHARD,)   F.  R.  C.  S. 

Assistant  Surgeon  Charing  Cross  Hospital,  <!ce. 


A  TREATISE  ON  DISEASES  OF  THE  JOINTS.     Illustrated  with  engrav- 

ings  on  wood.     In  one  very  handsome  octavo  volume,  of  about  500  pages,  extra  cloth;  $3  00. 

in^  and  faithful   delineations  of  disease. — London 
Med.  Times  and  Go.zetle,  Feb.  9,  1^61. 

This  volume  will  be  welcomed,  as  the  record  of 
mucti  honest  research  and  careful  investisration  into 


At  the  outset  we  may  state  that  the  work  is 
worthy  of  much  praise,  and  bears  evidence  of  much 
thoughtful  and  careful  inquiry,  and  here  and  there 
of  no  slight  originality.  We  have  already  carntd 
this  notice  further  than  we  intended  to  do,  but  not 
to  the  extent  the  work  deserves.  "We  can  only  add, 
that  the  perusal  of  it  has  afforded  us  great  pleasure. 
The  author  has  evidently  worked  very  hard  at  his 
subject,  and  his  investigations  into  the  Physiology 


the  nature  and  treatment  of  a  most  imiiortaut  class 
of  disorders.  We  cannot  conclude  this  notice  of  a 
valuable  and  ustful  hook  without  calling  attention 
to  the  amount  of  6o«a_^'f«  work  It  contains.  It  is  no 
slight  matter  for  a  volume  to  show  laborious  inves- 


and  Pathology  of  Joints  have  been  carried  on  in  a  i  tigatioi,,  and  at  the  same  time  original  thought,  on 
manner  which  entitles  hiui  to  be  listened  to  with  1  jj^^  p^rt  of  its  author,  whom  -n  e  may  congratulate 
attentKm  and  respect.    W  e  must  not  omit  to  men-  j  ^j,  tug  gaccessful  completion  of  his  arduous  task.— 
tion  the  very  admirable  plates  wnh  which  the  vo-     London  Lancet,  March  9,  1661. 
luoie  is  enriched.    We  seldom  meet  with  such  stnk-  I 


CARPENTER  (WILLIAM    B.),   M.  D.,  F.  R.  S.,  «tc., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London 

:THE  MICKOSCOPE  AND  ITS  REVELATIONS.      With  an  Appendix  con- 

taming  the  Applications  of  the  Micro.scope  to  Clinical  Medicine.  6zc.     By  F.  G.  Smith,  M.  D. 

Illustrated  by  four  hundred  and  thirty-four  beautiful  engravings  on  wood.    In  one  large  and  verj^ 

handsome  octavo  volume,  of  724  pages,  extra  cloth,  $5  00. 

The  great  importance  of  the  microscope  as  a  means  of  diagnosis,  and  the  number  of  microsco 
ipists  who  are  also  physicians,  have  induced  the  American  publishers,  with  the  author's  approval,  to 
add  an  Appendix,  carefully  prepared  by  Professor  Smith,  on  the  applications  of '.he  instrument  to 
clinical  medicine,  together  with  an  account  of  American  Microscopes,  thefr  modifications  and 
accessories.  This  portion  of  the  work  is  illustrated  with  nearly  one  hundred  wood-cuts,  and,  it  is 
hoped,  will  adapt  the  volume  more  particularly  to  the  use  of  the  American  student. 

Those  who  are  acquanued  with  Dr.  Carpenter's  [  The  additions  by  Prof.  Smith  give  it  a  positive 
previous  writings  on  Animal  and  Vegetable  Physio-  i  claim  upim  the  profession,  for  which  we  doubt  not 
logy,  willfully  understand  how  vasla  sloreof  know-  '  he  will  receive  their  sincere  thanks.  Indeed,  we 
ledge  he  is  able  to  bring  to  bear  upon  so  comprehen-  I  know  not  where  the  student  of  medicine  will  find 
sive  a  subject  as  the  revelations  of  the  microscope ;  I  such  a  complete  and  satisfactory  collection  of  micro- 
rtnd  even  those  who  have  no  previous  acquaintance  |  scopic  facts  bearing  upon  physiology  and  practical 
witii  the  c<mstruetiim  or  uses  of  this  instrument,  |  medicine  as  is  contained  in  Prof.  Smith's  appendix; 
will  find  abundanceof  information  conveyed  in  clear  and  this  of  itsell,  it  seems  to  us,  is  fully  worth  the 
uiU   simple  language. — Med.   Times  and   Gazerre.  I  cost  of  the  volume. — Louisville  Medical  Review. 


AND    SCIENTIFIC    PUBLICATIONS. 


CARPENTER  (WILLIAM   B.),   M.  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  applications  to 

Psychology,  Pathology,  Therapeutics,  Hygiene,  and  Forensic  Medicine.  A  new  American,  from 
the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations.  Edited,  with  addi- 
tions, by  Fra^jcis  Gurney  Smith,  M.  U.,  Prolessor  ofthe  Institutes  of  Medicine  in  the  Pennsyl- 
vania Medical  College,  &c.  In  one  very  large  and  heautitui  octavo  volume,  oi  about  nine  hundred 
large  pages,  handsomely  printed,  extra  cloth,  $5  00;  strongly  bound  in' leather,  with  raised  baadg, 
$6  00 

For  upwards  of  thirteen  years  Dr.  Carpenter's!  To  eulogize  thisgreat  work  would  be  superfluous, 
work  hiis  been  considered  by  tlie  profession  gene-  [  We  should  observe,  however,  that  in  this  edition 
rally,  both  in  this  country  and  England,  as  the  most ;  the  author  has  remodelled  a  large  portion  of  the 
valuable  compendium  on  the  subject  of  physiology  I  former,  and  the  editor  has  added  much  matter  of  in- 
in  our  language.  Thisdistinctionit  owes  to  the  high  terest,  especially  in  the  form  of  illustrations.  We 
attainments  and  unwearied  industry  of  its  accom-  :  may  confidently  recommend  it  as  the  most  complete 


plished  autlior.  Thepresent edition  (which, like  the 
last  American  one,  was  prepared  by  the  author  him- 
self), is  the  result  of  such  extensive  revision,  that  it 
may  almost  be  considered  a  new  work.  We  need 
hardly  say,  in  concluding  thisbrief  notice,  that  while 
the  work  is  indispensable  to  every  student  of  medi- 
cine in  this  country,  it  will  amply  repay  the  practi- 
tioner for  its  perusal  by  the  interest  and  value  of  its 
contents. — Boston  Med.  and  Surg.  Journal. 

This  is  a  standard  work — the  text-book  uSed  by  all 
medical  students  who  read  the  English  language. 
It  has  passed  through  several  editions  in  order'  to 
keep  pace  with  the  rapidly  growing  science  of  Phy- 
siology Nothing  ueed  be  said  in  its  praise,  for  its 
merits  are  universally  known  ;  we  have  nothing  to 
nay  of  its  defects,  for  they  only  appear  where  the 
science  of  which  it  treats  is  incomplete. — Western 
Lancet. 

The  most  complete  exposition  of  physiology  which 
any  language  can  at  present  give. — Brit,  and  For. 
Med.-Chirurg.  Review. 

The  greatest,  the  most  reliable,  and  the  best  book 
on  the  subject  which  we  know  of  in  the  English 
language. — Stethoscop$. 


work   on   Human    Physiology   in   our    language. — 
Southern  Med.  and  Surg.  Journal. 

The  most  complete  work  on  the  science  in  our 
language. — Am.  Med.  Journal. 

The  most  complete  work  now  extant  in  our  lan- 
guage.— N.  O.  Med.  Register. 

The  best  text- book  in  the  language  on  this  ex- 
tensive subject. — London  Med.  Times. 

A  complete  cyclopaedia  of  this  branch  of  eciencs. 
— iV.  Y.  Med.  Times. 

The  profession  of  this  country,  and  perhaps  also 
of  Europe,  have  anxiously  andfor  some  time  awaited 
the  announcement  of  this  new  edition  of  Carpenter's 
Human  Physudogy.  His  former  editions  have  for 
many  years  been  almost  the  only  text-book  on  Phy- 
siology in  all  our  medical  schools,  and  its  circula- 
tion am<mg  the  profession  has  been  unsurpassed  by 
any  work  in  any  department  of  medical  science. 

It  is  quite  unnecessary  for  us  to  speak  of  this 
work  as  its  merits  would  justify.  The  mere  aa- 
nouncement  of  its  appearance  will  afford  the  highest 
pleasure  to  every  student  of  Physiology,  while  its 
perusal  will  be  of  infinite  service  in  advancing 
physiological  science. — Okie  Med.andSurg.  Joxtm. 


BY   THE  SAME   AUTHOE. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 

LOGICAL  ANATOMY.     Second  American,  from  a  new  and  revised  London  edition.     Wili 

one  hundred  and  ninety  illustrations.     In  one  very  handsome  octavo  volume,  leather,    pp.  565. 

$3  50. 

In  publishing  the  first  edition  of  this  work,  its  title  was  altered  from  that  of  the  London  volume, 
by  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  luul  with  the  author's  sanctiiia 
the  title  of  "Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise. 

BY   THE   SAME   AUTHOR. 

PRINCIPLES  OF  COMPARATIVE   PHYSIOLOGY.     New  American,  from 

the  Fourth  and  Revised  London  edition.     In  one  large  and  handsome  octavo  volume,  with  over 
three  hundred  beautiful  illustrations,     pp.  752.     Extra  cloth,  $5  25. 


This  book  should  not  only  be  read  but  thoroughly 
studied  by  every  member  of  the  profession.  None 
are  too  wise  or  old,  to  be  benefited  thereby.  But 
especially  to  the  younger  class  would  we  cordially 
commend  it  as  best  fitted  of  any  work  in  the  English 
language  to  qualify  them  for  the  reception  and  com- 
prehension of  those  truths  which  are  daily  being  de- 
veloped in  physiology. — Medical  Counsellor. 

Without  pretending  to  it,  it  is  an  encyclopedia  of 
the  subject,  accurate  and  complete  in  all  respects — 
a  truthful  reflection  of  the  advanced  state  at  which 
the  science  has  now  arrived. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  truly  magnificent  work — in  itself  a  perfect  phy- 
siological study. — Ranking's  Abstract. 

This  worli  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken ;  it  is  one 


no  man,  we  believe,  could  have  brought  to  bosuo- 
cessful  an  issue  as  Dr.  Carpenter,  ft  required  tar 
its  production  a  physiologist  at  once  deeply  read  ia 
the  labors  of  others,  capable  of  taking  a  general, 
critical,  and  unprejudiced  view  of  those  labors,  and 
of  combining  the  varied,  heterogeneous  inuterialsat 
his  disposal,  so  a%to  form  an  harmoi.ious  whoie. 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  its  unity,  of  the  admirable  ma*  ner  in  which 
material  has  been  brought,  from  the  most  various 
sources,  to  conduce  to  its  conipletenes» ,  of  the  lucid- 
ity of  the  reasoning  it  c<mtain6,  or  of  the  clearness 
of  language  in  which  the  whole  is  clothed.  Not  the 
profession  only,  but  the  scientific  world  at  large, 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  this 
great  work.  It  must,  indeed,  add  Krgely  even  to 
his  high  reputation. — Medical  Timti. 


BY  THE  SAME  AUTHOR.     (Preparing.) 

PRINCIPLES  OP   GENERAL    PHYSIOLOGY,    INCLUDING   ORGANIC 

CHEMISTRY  AND   HISTOLOGY.     With   a  General  Sketch  ol   the  Vegetable  and  Animai 
Kingdom.     In  one  large  and  very  handsome  octavo  volume,  with  several  hundred  illustrations. 

BY   THE   SAME   AUTHOR. 

A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DISEASE.     New  edition,  with  a  Preface  by  D.  F.  Condie,  M.  D.,  and  explanatioHS  of 
■cientilic  words.    In  one  neat  12mo.  voliuue,  extra  cloth,    pp.  lib.    50  cents. 


BLANCHAKD   &  LEA'S  MEDICAL 


CONDIE  (D.  F.),  M.  D.,  «tc. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 


Fifth 

edition,  revised  and  augmented.    In  one  large  volume,  8vo.,  extra  cloth,  of  over  750  pages.  $3  "'5. 

In  presenting  a  new  and  revised  edition  ol  this  lavorite  work,  the  publishers  have  only  to  state 
that  the  author  has  endeavored  to  render  it  in  every  respt*cl  "a  complete  and  I'aithful  exposition  of 
the  pathology  and  thera])eulics  of  the  maladies  incident  to  the  earlier  stapes  of  existence — a  full 
and  exact  account  of  the  diseases  of  infancy  and  childhood."  To  accomplish  this  he  has  subjected 
the  whole  work  to  a  careful  and  thorough  revision,  rewriting  a  considerable  pHjrtion,  and  adding 
several  new  chapters.  In  this  manner  it  is  hoped  that  any  deliciencies  which  may  have  previously 
existed  have  been  supplied,  that  the  recent  labors  of  practitioners  and  observers  have  been  tho- 
roughly incorporated,  and  that  in  every  point  the  work  will  l>e  found  to  maintaiu  the  high  reputation 
it  has  enjoyed  as  a  complete  and  thoroughly  practical  book  of  reierence  in  infantile  afl'ections. 

A  few  notices  of  previous  editions  are  subjoined. 


Dr.  Condie's  scholarshij),  acumen,  industry,  and 
practical  sense  are  manifested  in  this,  as  in  all  his 
numerous  contributions  to  science. — Dr.  HolTnes'f 
Report  to  tht  American  Medical  Association. 

Taken  as  a  whole,  in  our  judgment,  Dr.  Condie's 
Treatise  is  the  one  from  the  perusal  of  which  the 
practitioner  in  this  country  will  rise  with  tlie  great- 
est satisfaction. —  Western'Journal  of  Medicine  and 
Surgery . 

One  of  the  best  worfes  upon  the  Diseases  of  Chil- 
dren in  the  English  language. —  Western  Lancet. 

We  leel  assured  from  actual  experience  tbat  nc 
physician's  library  can  be  complete  without  a  copy 
of  this  work. — N.  Y.  Journal  oj  Medicine. 

A  veritable  ptediatric  encyclopaedia,  and  an  honoi 
to  American  medical  literature. — Ohio  Medical  ana 
Surgical  Journal. 

We  feel  persuaded  that  the  American  medical  pro- 
'feission  will  soon  regard  it  pot  only  as  a  very  good. 
tt-At  as  the  VERT  best  "  Practical  Treatisn,  on  the 
iiiseases  of  Children." — American  Medical  Journal 
Jn  the  department  of  infantile  therapeutics,  the 
work  of  Dr.  Ctmdie  is  considered  one  of  the  best 
which  lias  been  published  in  the  English  language. 
—4tke  Stethoscope. 


We  pronounced  the  first  edition  to  be  the  beat 
work  on  the  diseases  of  children  in  the  English 
language,  and,  notwithstanding  all  that  has  been 
published,  we  still  regard  it  in  that  light. — Medical 
Examiner. 

The  value  of  works  by  native  authors  on  the  dis- 
eases which  Che  physician  is  called  upon  to  combat, 
will  be  Hiiprcciated  by  all ;  an  I  the  work  of  Dr.  Con- 
dit  has  gained  for  itself  the  character  of  a  safe  guide 
lor  stuUeniB,  and  a  useful  work  for  consultation  by 
thoae  engaged  in  practice. — N.  Y.  Med    Tinus. 

This  IS  the  fourth  edition  of  this  deservedly  popu- 
lar treatise.  During  the  interval  since  the  last  edi- 
tion, it  has  been  subjected  to  a  thorough  revision 
by  the  author;  and  all  new  observations  in  the 
pathology  and  therapeutics  of  children  have  been 
included  in  the  present  volume.  As  we  said  bifore, 
we  do  not  kno'w  of  a  better  book  on  diseases  of  cnil- 
dien,  and  to  a  large  partot  its  recomnumla  lions  we 
yield  an  unhesitating  concurrence. — Buffalo  Med. 
Tournal. 

Perhaps  the  most  full  and  complete  work  no  Af  be- 
ore  the  profession  of  the  United  States;  indeed,  we 
nay  say  in  the  English  language.  It  is  vastly  supe- 
rior to  luostof  ilspretiecessors. — Transylvania Mtd. 
Journal 


CHRISTISON  (ROBERT),  M.  D.,  V.  P.  R.  S.  E.,  &c. 
A  i>ISPENSAT01lYj  or,  Commeutary  on  the  Pharmacopoeias  of  Great  Britain 

and  the  United  Stales;  comprising  the  Natural  History,  Description,  Chemistry,  Pharmacy,  Ac- 
tioiiS,  Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica.  Second  edition,  revised  and  im- 
proved, with  a  Supplement  containing  the  most  important  New  Remedies.  With  copious  Addi- 
tions, and  two  hundred  and  thirteen  large  wood-engravings.  By  K.  Eglesfeld  Griffith,  M.  D. 
In  oae  very  large  and  handsome  octavo  volume,  extra  cloth,  of  over  1000  pages.   $3  50. 


COOPER  (BRANSBY   BJ,  F.  R.  S. 
LECTURES  ON  THE   PRINCIPLES   AND   PRACTICE  OP   SURGERY. 

In  one  very  large  octavo  volume,  extra  cloth,  of  750  pages.    $3  00. 


COOPER  ON  DISLOCATIONS  AND  FRAC- 
TURES OF  THE  JOINTS.— Edited  by  Bra.nsby 
B.  Cooper,  F.R.S.,  &c.  With  additional  Ob- 
servations by  Prof.  J.  C.  Warren.  A  new  Ame- 
rican edition.  In  one  handsome  octavo  volume, 
extra  cloth,  of  about  50(1  pages,  with  numerous 
illustrations  on  wood.    $3  25. 

COOPER  ON  THE  ANATOMY  AND  DISEASES 
OF  THE  BREAST,  with  tw%nty-five. Miscellane- 
ous and  Surgical  Papers.  One  large  volume,  im- 
perial 6vo.,  extra  cloth,  with  '^52  figures,  on  36 
plates.     S*2  50. 

COOPER  ON  THE  STRUCTURE  AND  DIS- 
EASES OF  THE  TESTIS,  AND  ON  THE 
THYMUS  GLaND.  One  vol.  imperial  bvo.,  ex- 
tra cloth,  with  177  tigures  on  29  plates.    $2  UO. 


COPLAND  ON  THE  CAUSES,  NATURE.  AND 
TREATMENT  OF  PALSY  AND  APOPLEXY. 
In  one  volume,  royal  12mo.,  extra  cloth,  pp.  326. 
60  cents. 

CLYMER  on  FEVERS;  THEIR  DIAGNOSIS, 
PATHOLOGY,   AND    TREATMENT.     In  one 

octavo  volume,  leather,  of  6U0  pages.     $1  50. 

COLOMBAT  DE  L'ISERE  ON  THE  DISEASES 
OF  FEMALES,  and  on  the  special  Hygiene  of 
their  Sex.  Translated,  with  many  Notes  and  Ad- 
ditions, by  C.  D.  Meigs,  M.  D.  Second  edition, 
revised  and  improved  In  one  large  volume,  oc- 
tavo, leather,  with  uuiuerous  wood-cuts.  pp.  720. 
Sa  50. 


CARSON  (JOSEPH),  M .  D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania. 

V  SYNOPSIS  OF  THE  COURSE  OP  LECTURES  ON  MATERIA  iMEDICA 

AND  PHARMACY,  delivered  in  the    University  of  PeiuL-rylvania      Wi  h  three  Lectures  on 
the  Modus  Operandi  of  Medicines.     Third  edition,  revised.     In  one  handsome  octavo  volume. 
.  (iVow7  Reody.)     $2  25. 

CURLING    (T.    BJ,    F.R.S., 
Surgeoa  to  the  London  Hospital,  President  of  the  Huuterian  Society,  Ac. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS,  SPERMA- 

TIC  CORD,  AND  SCROTUM.     Second  American,  from  the  second  and  enlarged  English  edi- 
lioa.    In  one  handsome  octavo  volume,  exti  a  cloth,  with  numerous  illuairaiions.  pp.  4^0.  $2  00 


AND    SCIENTIFIC    PUBLICATIONS. 


CHURCHILL  (FLEETWOOD),  t^.  D.,  M .  R.  \.  K. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.     A  new  American 

from  the  foiirlh  revised  and  enlarged  London  edition.  With  Notes  and  Additions,  by  D.  Francis 
UoNDiE,  M.  D.,  author  o(  a  "Practical  Treati.-e  on  thr^  Uiseas^^  of"  Children,"  iVr  With  194 
illustrations.     In  one  very  handsome  octavo  volume,  of  nearly  700  large  pages,  extra  cloth,  $3  75. 

This  work  has  been  so  long  an  established  favorite,  both  as  a  text-book  for  the  learner  and  as  a 
reliable  aid  in  consuliation  lor  the  praciitioner,  that  in  presenting  a  new  edition  it  is  only  necessary 
to  call  attention  to  the  very  extended  improvements  which  it  has  received  Having  had  the  benefit 
of  two  revisions  by  the  author  ^ince  the  last  American  reprint,  it  has  been  materially  enlarared,  and 
Dr.  Churchill's  well-known  conscientious  industry  i<  a  s^uarantee  that  every  portion  has  been  tho- 
roughly brought  up  with  the  latest  results  of  European  investi^^alion  in  all  departments  of  the  sci- 
ence and  art  of  obstetrics.  The  recent  dale  of  the  lust  Dublin  edition  has  not  left  much  of  novelty 
for  the  American  editor  to  introduce,  but  he  has  endeavored  to  insert  whatever  ha'*  since  appeared, 
together  with  such  matters  as  his  experience  has  shown  him  would  be  desirable  for  the  Anidrican 
student,  including  a  large  number  of  illustrations.  Wiih  the  sanction  of  the  author  he  has  added 
in  the  form  of  an  appendix,  some  chapters  from  a  little  "Manual  for  Midwivc  and  Nurses,"  re- 
cently issued  by  Dr.  Churchill,  believing  'hat  the  details  there  presented  can  hardly  fail  to  prove  of 
advantage  to  the  junior  practitioner.  Tne  result  of  all  these  acditiiins  is  that  the  work  now  con- 
tains fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one-half  more  illus- 
trations, so  that  n'>twithstanding  the  use  of  a  smaller  type,  the  volume  contains  almost  two  hundred 
pages  more  than  before. 

No  effort  has  been  spared  to  secure  an  improvement  in  the  mechanical  execution  of  the  work 
equal  to  that  which  the  text  has  received,  and  the  volume  is  confidently  presented  as  one  of  the 
handsomest  that  has  thus  far  been  laid  before  the  American  profession;  while  the  very  low  price 
at  which  it  is  offered  should  secure  for  it  a  place  in  every  lecture-room  and  on  every  office  table. 


A  better  book  in  which  to  learn  these  important 
points  We  havt  nut  met  ihan  Dr.  Churchill's  Every 
psge  of  it  is  full  of  instruction  ;  the  Ofiinion  of  all 
writers  of  authority  is  given  on  questions  of  diffi- 
culty, as  well  as  tlie  directions  and  advice  ot  the 
learned  autiior  himself,  to  which  tie  adds  the  result 
of  statistical  inquiry,  putting  statistics  in  their  pro 
per  place  and  giving  them  their  Hue  weight,  and  no 
more.  We  have  never  read  a  book  more  free  from 
professional  jralousy  tlian  Dr.  Churchill's.  It  ap- 
pears to  be  written  with  the  true  design  of  a  book  on 
medicine,  viz:  to  give  all  that  is  known  on  the  sub- 
ject of  which  he  treats,  both  theoretically  and  prac- 
tically, and  to  advance  such  opinions  of  tiis  own  as 
he  believes  will  benefit  mtdieal  scitnee,  and  insure 
the  safety  of  the  patient.  We  have  said  enough  to 
convey  to  the  profession  that  this  book  of  Dr.  Cnur- 
cnili's  is  admirably  suited  for  a  book  of  reference 
for  the  pmctilinner,  as  well  as  a  text-book  for  the 
student,  and  we  hope  it  may  be  extensively  pur- 
chased amongst  our  readers.  To  them  we  most 
strongly   recommend   it.  —  Dublin   Medical   Press 

To  bestow  praise  on  a  book  that  has  received  such 
marked  approbation  would  be  superfluous.'  We  need 
•only  say,  therefore,  that  if  the  first  edition  ^vas 
thought  worthy  of  a  favorable  reception  by  the 
medical  public,  we  can  confidently  affirm  that  this 
will  be  found  much  more  so.  The  lecturer,  the 
practitioner,  and  the  student,  may  all  have  recourse 
to  its  pages,  and  derive  from  their  perusal  much  in- 
terest and  instruction  in  everything  relating  to  theo- 
retical and  practical  midwifery. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  work  of  very  great  merit,  and  such  as  we  can 
eonfidently  recommend  to  the  study  of  every  obste- 
tric practitioner. — London  Medical  Gazette. 

Few  treatises  will  be  found  better  adapted  as  » 
text-book  for  the  student,  or  as  a  manual  for  th( 
frequent  consultation  of  tiie  young  practitioner. -- 
American  Medical  Journal. 


Were  we  reduced  to  the  necessity  of  having  but 
>n«  work  on  midwifery,  and  permitted  to  choose, 
ve  would  unhesitatingly  take  Churchill. —  Western 
\[ed.  and  Surg.  Journal. 

It  is  impossible  to  conceive  a  more  useful  acd 
ilegant  manual  than  Dr.  Churchill's  Practice  of 
Vlidwifery. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
'le  subject  which  exists.— ^/V.  Y.  Annalist. 

No  work  holds  a  higher  position,  or  is  more  de- 
serving of  being  placed  in  the  hands  of  the  tyro, 
the  advanced  student,  or  the  practitioner. — Medical 
Examiner . 

Previous  editions  have  been  received  with  mark- 
ed favor,  and  they  deserved  it;  but  this,  reprinted 
from  a  very  late  Dublin  editKm,  carefully  revised 
and  brought  up  by  the  author  to  the  present  tiine^ 
does  present  an  unusually  accurate  and  able  expo- 
sition of  every  important  particular  embraced  in 
the  departmentof  midwifery.  *  *  The  clearness, 
directness,  and  precision  of  its  teachings,  together 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  in 
the  foremost  rank  of  works  in  this  department  of  re- 
medialscience. — N.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  the 
very  best  text-book  and  epitome  of  obstetric  seienca 
which  we  at  present -possess  in  the  English  lan- 
guage.—  Monthly  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  greatamountof  statistical  research 
which  it  contains, have  served  to  place  it  in  the  first 
rank  of  works  in  this  departmentof  medical  science. 
—  N.  Y.  .Tournnl  of  Medicine. 

This  is  certainly  the  most  perfect  system  extant. 
ft  is  the  best  adapted  for  the  purposes  of  a  text- 
look,  and  that  which  he  whose  necessities  confine 
lim  to  one  book,  should  select  in  preference  to  all 
)thers. — Southern  Medical  and  Surgical  Journal. 


BY  THK  SAME  AUTHOR.     {Lately  Published.) 

ON  THE  DISEASES  OF  INFANTS   AND   CHILDREN.     Second  American 

Edition,  revised  aiid  enlarged  by  the  author.    Edited,  with  Notes,  by  W.  V.  Keating,  M.  D.    In 

one  large  and  handsome  volume,  extra  cloth,  of  over  700  pages.    $3  50. 

In  preparing  this  work  a  second  time  for  the  American  profession,  the  author  has  spared  no 
labor  in  giving  it  a  very  thorough  revision,  introducing  several  new  chapters,  and  rewriting  others, 
•while  every  portion  of  the  volume  has  been  subjected  to  a  severe  scrutiny.  The  efforts  of  the 
American  editor  have  been  directed  to  supplying  such  information  relative  to  matters  peculiar 
to  this  country  as  might  have  escaped  the  attention  of  the  author,  and  the  whole  may,  there- 
fore, be  safely  pronounced  one  of  the  most  complete  works  on  the  subject  accessible  to  the  Ame- 
rican Profession.  By  an  alteration  in  the  size  of  the  page,  these  very  extensive  additions  have 
been  accommodated  without  unduly  increasing  the  size  of  the  work. 

BY  THE   SAME   AUTHOR. 

ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES  PE- 
CULIAR TO  WOJVIEN.  Selected  from  the  writingsot  British  Authors  previous  to  the  close  of 
the  Eighteenth  Century.    In  one  neat  octavo  volume,  extra  cloth,  of  about  4.o0  pages.    $2  50. 


10  BL.ANCHARD    &    LEA'S    MEDICAL 

CHURCHILL  (FLEETWOOD),    M .  D.,  M .  R.  I .  A.,    «tc. 
ON  THE  DISEASES  OF  WOMEN;  including  those  of  Pregnancy  and  Child- 

bed.    A  new  American  edition,  revised  by  the  Author     With  Note?  and  Additions,  by  D   Fran- 
cis CoNDiE,  M.  D.,  author  ot  "A  Practical  Treatise  on  the  Diseases  of  Children."    With  nume- 
rous illustrations.     In  one  large  and  handsome  octavo  volume,  extra  cloth,  of  768  pages.    $3  50. 
This  edition  ol  Dr.  Churchill's  very  popular  treatise  may  almost  be  termed  a  new  work,  so 
thoroughly  has  he  revised  it  in  every  portion.     It  will  be  found  greatly  enlarged,  and  completely 
brought  lip  to  the  mo-<i  recent  condition  ol  the  subject,  while  the  very  hand.-ome  series  of  illustra- 
tions introduced,  representiifg  such  pathological  conditions  as  can  be  accurately  portrayed,  present 
a  novel  feature,  and  afl'ord  valuable  assisiaiice  to  the  young  practitioner.     Such  additions  as  ap- 
peared desirable  for  the  American  student  have  been  made  by  the  editor,  Dr.  Condie,  while  a 
marked  improvement  in  the  mechanical  execution  keeps  pace  with  the  advance  in  all  other  respects 
which  the  volume  has  undergone,  while  the  price  has  been  kept  at  the  former  very  moderate  rate. 


It  ciimprises,  unquestionably,  one  of  the  most  ex- 
act ami  comprehensive  expositions  of  the  present 
state  of  medical  knowledge  in  respect  to  the  diseases 
of  wnmen  that  has  yet  been  published. — Am.  Journ. 
Med.  Sciences. 

This  work  is  the  most  reliable  which  we  possess 
on  this  subject ;  and  is  deseiveilly  popular  with  tlie 
profession. — Charleston  Med.  Journal,  July,  1857. 

We  know  of  no  author  who  deserves  that  appro- 
bation, on  "the  diseases  of  females,"  to  the  same 


extent  that  Dr.  Churchill  does.  His,  indeed,  is  the 
only  thorough  treatise  w^e  know  of  on  the  subject; 
and  it  may  be  commended  to  practitioners  and  stu- 
dents as  a  masterj)iece  in  its  particular  department. 
— Tki  Western  Journal  of  Medicine  and  Surgery. 

Ab  a  comprehensive  manual  for  students,  or  a 
work  of  reference  for  practitioners,  it  surpasses  any 
other  that  has  ever  issued  on  the  same  subject  from 
the  British  press. — Dublin  Quart.  Journal . 


DICK-SON   (S.    H.),    M.  D., 

Professor  of  Practice  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

ELEMENTS  OF  MEDICINE;  a  Compendious  View  of  Pathology  and  Thera- 
peutics, or  the  History  and  Treatment  of  Di.seases.  Second  edition,  revised.  In  one  large  and 
handsome  octavo  volume   ol  750  pages,  extra  cloth.     S3  75. 

The  steady  demand  which  has  so  soon  exhausted  the  first  edition  of  this  work,  sufficiently  shows 
that  the  author  was  not  mistaken  in  supposing  that  a  volume  of  this  character  was  needed — an 
eleniemary  manual  of  practice,  which  should  present  the  leading  principles  of  medicine  with  the 
practical  results,  in  a  copdensed  and  perspicuous  manner.  Disenrcumbered  of  unnecessary  detail 
and  truiiless  speculations,  it  embodies  what  is  most  requisite  for  the  student  to  learn,  and  at  the 
same  time  what  the  active  practitioner  wants  when  obliged,  in  the  daily  calls  of  his  profession,  to 
refresh  his  nieiTiory  on  special  points.  The  clear  and  attractive  style  of  the  author  renders  the 
whole  ea^y  of  comprehension,  while  his  long  experience  gives  to  his  teachings  an  authority  every- 
where acknowledged.  Few  physicians,  indeed,  have  had  wider  opportunities  for  observation  and 
experience,  and  few,  perhaps,  have  used  them  to  better  purpose  As  the  result  of  a  long  life  de- 
voied  to  study  and  practice,  the  present  edition,  revised  and  brought  up  to  the  date  of  publication, 
will  doubtless  maintain  the  reputation  already  acquired  as  a  condensed  and  convenient  American 
texi-book  on  the  Practice  of  Medicine. 


DRUITT   (ROBERT),   M.R.C.S.,   &.C. 
THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY.     A  new 

and  revi>ed  American  from  the  eighth  enlarged  and  improved  London  edition.     Illustrated  with 

four  hundred  and  thirty-two  wood-engravings.    In  one  very  handsomely  printed  octavo  volume 

of  nearly  700  large  pages,  extra  cloth,  $3  75. 

A  work  which  like  Druitt's  Surgery  has  for  so  many  years  maintained  the  position  of  a  lead- 
ing favorite  with  all  classe*  of  the  profession,  needs  no  S'pecial  recommendation  to  attract  attention 
to  a  revi?ed  edition.  It  is  only  necessary  to  state  that  the  author  has  spared  no  pains  to  keep  the 
work  up  to  its  well  earned  reputation  of  presenting  in  a  small  and  convenient  compass  the  latest 
condition  of  every  department  of  surgery,  considered  both  as  a  science  and  as  an  art;  and  that  the 
services  of  a  competent  American  editor  have  been  employed  to  introduce  M'hatever  novelties  may 
have  ei-caped  the  author's  attention,  or  may  prove  of  service  to  the  American  practitioner.  As 
several  editions  have  appeared  in  London  since  the  issue  of  the  last  American  reprint,  the  volume 
has  had  the  benefit  of  repeated  revisions  by  the  author,  resulting  in  a  very  tnorough  alteration  and 
improvement.  The  extent  of  these  additions  may  be  estimated  from  the  tact  that  it  now  contains 
about  one- third  more  matter  than  the  previous  "American  edition,  and  that  notwithstanding  the 
adoption  of  a  smaller  type,  the  pages  have  I>een  increased  by  about  one  hundred,  while  nearly  two 
hundred  and  fiftv  wood-cuts  have  been  added  to  the  former  list  of  illustrations. 

A  marked  improvement  will  also  be  perceived  in  the  mechanical  and  artislical  execution  of  the 
work,  wfiich,  primed  in  the  best  style,  on  new  tj  pe,  and  fine  paper,  leaves  little  to  l^e  desired  as 
regards  external  finish;  while  at  the  very  low  price  affixed  it  will  be  fotmd  one  of  the  cheapest 
volumes  accessible  to  the  profession. 

This  popular  volume,  no-w  a  most  comprehensive  '  nothing  of  real  practical  importance  has  been  omit- 
work  on  surgery,  has  undergone  many  corrections,  ted;  it  presents  a  faithful  epitome  of  everything  re- 
improvemeuis,  and  additions,  and  the  principles  and  ,  lating  t  >  surgery  up  to  the  present  hour.  It  is  de- 
the  practice  of  the  art  have  been  brought  down  to  serveUly  a  popular  manual,  both  with  the  student 
the  latest  record  .nnd  obeervation.  Of  the  operations  and  practitioner. — London  Lancet,  Nov.  19,  1859. 
in  snieery  it  is  impoRSible  to  speak  toohighiy.  The  ,  ,  .  .,  •  ,  ■  r  .„„  ,,  .«„„„„„„j  „.  „^. 
de.r-rip,ionsaresocl.ar>.ndc„ncise,andthenius-  In  closing  this  brief  notice,  we  recommend  as  cor- 
trations  so  accurate  and  numerous,  that  the  student  ,  fial  Iv  as  ever  this  most  useful  anu  comprehensive 
can  have  no  dirticulty .  with  instrument  in  hand,  and  I'and-bouk.  Il  must  pr,.ve  a  vast  «ssibtauce  not 
b<  ok  l.v  his  side,  over  ih-  .lead  b<.dy,  in  obtainin?  ,  <"">•  t'/. ""-  ^^""t'"  "^ ^''fe^^>''  ^,Y,  "'^^'  '",^''-^  ''"^^ 
a  proper  knc-wlerige  and  sufficient  tact  m  this  nuich  practitioner  wh.  may  not  have  the  leisure  to  devote 
neglectedoeparlmenlof  .ned.caleducUion.-/.r,(Ks/,  ''""""'f  '<;  the  study  of  more  lengthy  vournes.- 
and  Foreign  Mtdico-Vkirurg.  Heview,  Jan.  ISCO  London  Med.  Tunes  and  Gazette,  Oct  22,  l^o9. 


In  the  present  edition  the  author  has  entirely  re- 
written many  nf  the  chapters,  and  has  incorporated 
the  various  improvemenis  and  additions  in  modern 
■urgery.    On  carefully  going  over  it,  we  find  that 


In  a  word,  this  eighth  edition  of  Dr  Druitt's 
Manual  of  Surgery  is  all  that  the  surgical  student 
or  practitioner  could  desire.  —  Dublin  Quart$rlf 
Journal  of  Med.  Sciences,  Nov.  1859. 


AND    SCIENTIFIC    PUBLICATIONS. 


11 


DALTOIM,   JR.  (J.   C),   M.   D. 

Professor  of  Physiology  in  the  College  of  Physicians,  New  York. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY,  designed  for  the  use  of  Students 

and  Practitioners  of  Medicine.  Tliird  edition,  revised,  with^iearlv  three  hundred  illustrations 
on  wood.  In  one  very  beautiful  octavo  volume,  of  700  pages,  extra' cloth,  $4  75.  (Just  Kecuiv, 
1864.;  .  >  V  .?. 

The  rapid  demand  for  another  edition  of  this  work  sufTiciently  .*hows  that  the  author  hat  i^uc- 
ceeded  in  his  eftbrts  to  produce  a  text-book  of  standard  and  permanent  value,  embodying  within 
a  moderate  compass  all  that  is  detinitely  and  positively  known  within  the  domain  of  Human 
Physiology  His  high  reputation  as  an  original  ob.-^erver  and  investigator,  is  a  guarantee  that  in 
again  revising  it  he  has  introduced  whatever  is  necessary  to  render  il  thoroughly  on  a  level  with 
the  ad'-anced  science  of  the  day,  and  this  has  been  accomplished  without  unduly  increasing  the 
size  of  the  volume. 

No  exertion  has  been  spared  to  maintain  the  high  standard  of  typographical  execution  which  has 
rendered  this  work  admittedly  one  of  the  handsomest  volumes  as  yet  produced  in  this  coun  ry. 

It  will  be  seen,  therefore,  that  Dr.  Dalton's  best  i  own  originnl  views  nn<\  experiments,  tngether  with 
efforts  have  been  directed  towards  perfecting  his  *  a  desire  to  supply  what  he  considered  some  deficien- 
work.  The  additions  are  marked  b>  tlie  same  fea-  !  cies  in  the  first  edition,  have  already  made  the  pre- 
tures  which  characterize  the  remainder  of  the  vol-  1  sent  one  a  necessity,  and  it  will  no'  doubr  be  even 
nine,  and  render  it  by  far  the  must  desirable  text-  ■•  more  eagerly  sought  for  than  the  first.  That  it  is 
book  on  physiology  to  place  in  the  hands  of  the  j  not  merely  a  reprint,  will  be  seen  from  the  author's 
student  which,  so  far  as  we  are  aware,  exists  in  statement  of  the  fol'owing  principal  additions  und 
the  English  language,  or  perhaps  in  any  other.  We  alterations  which  he  has  made.  The  present,  hke 
therefore  have  no  hesitation  in  recommending  Dr.  the  first  edition,  is  printed  in  the  highest  style  of  the 
Dalton's  book  for  the  classes  for  which  it  is  intend-  '  printer's  art,  and  the  illustrations  are  truly  adinira- 
ed,  satisfied  as  we  are  that  it  is  better  acapted  to  i  ble  tor  their  clearness  in  e-xpressiug  exactly  what 
their  ufe  than  any  other  work  of  the  kind  to  which  '•  their  author  intended.— i?ns«on  Medical  and  Surgi- 
they  have  access. — American  Journal  of  the  Med.  cal  Journal,  March  28,  1861. 
Sciences,  April,  1861.  I      r    ■ 

It  IS  unnecessary  togive  a  detail  of  theadditions; 

It  is,  therefore,  no  disparagement  to  the  many  '  suflSce  it  to  say,  that  they  are  numerous  and  import- 
books  upon  piiysiology,  most  excellent  in  their  day,  ant,  and  such  as  will  render  the  worK  still  more 
to  say  that  Dalton's  is  the  only  ime  that  gives  us  the  valuuhle  and  acceptable  to  the  prot'essinn  as  a  leara- 
science  as  it  was  known  to  the  best  philosophers  :  ed  and  original  treatiseon  this  all-iaiportant  branch 
throughout  the  world,  at  the  beginning  of  the  cur-  i  of  medicine.  All  that  was  said  in  commendation 
rent  year.  It  states  in  comprehensive  but  concise  '  of  the  getting  up  of  the  first  edition,  and  the  superior 
diction,  the  facts  established  by  experiment,  or  ;  style  of  the  illustrations,  apply  with  equal  foice  to 
other  method  of  demonstration,  and  details,  in  an  this.  No  better  work  on  physiology  can  be  placed 
nndcrstaudable  manner,  how  it  is  done,  butatjstains  in  the  hand  of  the  student. — St.  Louis  Medical  and 
from  thediscussion  of  unsettled  or  theoretical  points.    Surgical  Journal,  May,  1861. 

Herein  it  if  unique  ;  and  these  charactei-istics  re n  These  additions,  while  tes  ifying  to  the  learning 

fler  it  a  text-book  wi  hout  a  rival,  for  hose  who  ;  ^nd  industry  of  the  author,  render  the  book  exceed- 
desire  to  study  physiological  science  as  it  is  known  ^     u^^f^,    ^^^  ^^^  ^^^^  complete  expose  of  a  s.-i- 

to  .ts  most  successful  cultivators.     And  it  is  physi-    ^nce,  of  which  Dr.  Dalton  is  doubtless  the  ablest 
ology  thus  presented  that    les  at  the  foundation  of    representative  on  this  side  of  the  Atlantic .-iVe«. 
correct,  pathologica    knowledge;  and  this  in  turn  is  ,  Orleans  Med    Times,  May,  1861. 
the  basis  of  rational  therapeutics;   so  that  path  ilo-  I 

gy,  in  fact,  becomes  of  prime  importance  in  the  I  ,  A  second  edition  of  this  deservedly  popular  work 
proper  discharge  of  our  every-day  practical  duties.  "«ving  been  called  for  in  the  short  space  of  two 
—Cincinnati  Lancet,  May,  1861.  !  years,  the  author  has  sup)  lied  deficiencies,  which 

[existed  in  the  former  volume,  and  has  thus  more 
Dr.  Dalton  needs  no  word  of  praise  from  us.  He  completely  fulfilled  his  design  of  presenting  to  th- 
is universally  recognizeo  as  among  the  first,  if  not  professicm  a  reliable  and  precise  text  book,  and  one 
the  verv  fiist, of  American  physiologists  now  living.  ;  which  we  consider  the  best  outline  on  the  subject 
The  first  edition  of  hi.s  admirable  work  appeared  but  of  which  it  treats,  in  any  language. — N.  American 
two  years  since,  and  the  advance  of  science,  his    Medico-Ckirurg.  Review,  May,  1861. 


DUNGLISON,    FORBES,   TWEEDIE,    AND   CONOLLY. 
THE  CYCLOPAEDIA.  OP  PRACTICAL  MEDICINE:  comprising  Treatises  od 

the  Nature  and  Treatment  of  Diseases,  Materia  Medica,  and  Therapeutics,  Diseases  of  Women 
and  Children,  iVIedieal  Jurisprudence,  <fec.  &c.  In  four  large  super-royal  octavo  volumes,  ol 
3254  double-columned  pages,  strongly  and  handsomely  bound,  with  raised  bands.  $14  00. 
*iif*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed  by 
■ixty-eight  distinguished  physicians,  rendering  it  a  complete  library  of  reference  for  the  country 
practitioner. 

The  editors  are  practitioners  of  established  repu- 
tation, and  the  list  of  contributors  embraces  many 
of  the  most  eminent  professors  and  teachers  of  Lon- 
don, Edinburgh,  Dublin,  and  Glasgow.  It  is,  in- 
deed, the  great  merit  Ol  this  work  that  the  principal 
articles  have  been  furnished  by  practitioners  who 
have  not  only  devotee  especial  attenti<in  to  the  dis 
eases'  about  which  they  have  written,  but  have 
also  enjoyed  opportunitief  for  an  extensive  practi- 
cal acquaintance  with  them  and  whose  reputation 
carries  the  assurance  of  their  competency  justly  to 
appreciate  the  opinions  ol  others,  while  it  stamps 
their  own  doetrir.es  wit!  high  and  just  authority. — 
Arnerican Medical  Journal. 


The  most  complete  work  on  Practical  Medicine 
•xtant;  or,  at  least,  in  our  language. — Buffalo 
Medical  and  Surgical  Journal. 

For  reference,  it  is  above  all  price  to  every  prac- 
titioner.—  Western  Lancet. 

One  of  the  most  valuable  m«dical  publications  of 
the  day — as  a  work  of  reference  it  is  invaluable. — 
Western  Journal  oj  Medicine  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher, a 
work  for  ready  and  frequent  reference,  one  in  which 
modem  English  medicine  is  exhibited  in  the  most 
advantageous  light. — Medical  Examiner. 


DEWEES'S  COMPREHENSIVE  SYSTEM  OF 
MIDWIFERY.  Illustrated  by  occasional  cases 
and  many  engravings.  Twelfth  edition,  with  the 
author's  last  improv^ents  and  corrections  In 
oneoctavovolume,  extra  cloth,  of  6110  pages.  $320, 

DEWEES'S  TREATISE  ON   THE  PHYSICAL 


AND  MEDICAL  TREATMENT  OF  CHILD 
REN.  The  last  edition.  In  one  volume,  octavo, 
extpa  cloth,  518  pages      S2  80 

OEWEES'S  TREATISE  ON  THE  DISEASES 
OF  FEMALES.  Tenth  edition.  In  one  volume, 
octavo  extra  cloth,  532  pages,  with  plates.  $3  00. 


12 


BLANCHARD    &    LEA'S    MEDICAL 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

NEW  Ain>  ENLARGED  EDITION. 
MEDICAL  LEXICON;   a  DictioDary  of  Medical  Science,  containing  a  concise 

Explanation  of  tiie  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutics  Pharmacology,  Pharmacy,  Surgery,  Obsieirics,  Medical  Jurisprudence,  Dentistry, 
&:c.  Notices  ofClintate  and  of  Mineral  Waters;  Formula;  for  Otficinal,  Empirical,  and  Dietetic 
Preparations.  &c.  With  French  and  other  Synonymes.  Revi-ed  and  very  greatly  enlarged. 
In  one  very  large  and  handsome  octavo  volume,  of  992  double-columned  pages,  in  small  type; 
Btrongly  bound  in  leather.    Price  $4  00. 

Especial  care  has  been  devoted  in  the  preparation  of  this  edition  to  render  it  in  every  respect 
worthy  a  continuaTice  of  the  very  remarkable  favor  which  it  has  hitherto  enjoyed.  The  rapid 
gaie  of  Fifteen  large  editions,  and  the  coitsiantly  increasing  demand,  show  that  it  is  regarded  by 
the  profession  as  the  standard  authority.  Stimulated  by  this  fact,  the  author  has  endeavored  in  the 
present  revision  to  introduce  whatever  might  be  necessary  "  to  make  it  a  satisfactory  and  desira- 
ble— il  not  indispensable — lexicon,  in  which  the  student  may  search  without  disappointment  for 
every  term  that  has  been  legitimated  in  the  nomenclature  of  the  science."  To  accomplish  this, 
large  additions  have  been  found  requisite,  and  the  extent  of  the  author's  labors  may  be  estimated 
from  the  fact  that  about  Six  Thousand  subjects  and  terms  have  been  introduced  throughout,  ren- 
dering the  whole  number  of  definitions  about  Sixty  Thot'sand,  to  accommodate  which,  the  num- 
ber of  pages  has  been  increased  by  nearly  a  hundred,  notwiihstandmg  an  enlargement  in  the  size 
of  the  paae.  The  medical  press,  both  in  this  country  and  in  England,  has  pronounced  the  work  in- 
dispensable to  all  medical  students  and  practitioners,  and  the  present  improved  edition  will  not  lose 
that  enviable  reputation. 

The  publishers  have  endeavored  to  render  the  mechanical  execution  worthy  of  a  volume  of  such 
universal  use  in  daily  reference.  The  greatest  care  has  been  exercised  to  obtain  the  typographical 
accuracy  so  necessary  in  a  work  of  the  kind.  By  the  small  but  exceedingly  clear  type  employed, 
an  immense  amount  of  matter  is  condensed  in  its  thousand  ample  pages,  while  the  binding  will  be 
found  strong  and  durable.  With  all  these  improvements  and  enlargements,  the  price  has  been  kept 
a  t  the  former  very  moderate  rate,  placing  it  within  the  reach  of  all. 


This  work,  the  appearance  of  the  fifteenth  edition  I 
of  which,  it  has  betome  our  duty  and  pleasure  to  i 
announce, is  perhaps  the  most  stupendous  niimument 
of  liiliiir  and  erudilion  in  medica!  literature.     One 
would  hardly  suppose  after  constant  use  of  the  pre- 
eec'iiis  editions,  where  we  have  never  failed  to  find  j 
a  sufficiently  full  explanation  of  everj  medical  term,  ] 
that   in  fills  edition  ^^  about  six   thousand  subjects 
and  ttrms  have  been  added,''''  with  a  careful  revision 
an<l  correction  of  the  entire  work.     It  is  only  nects- 
8ary  to  announce  the  advent  of  this  edition  to  make 
it  occupy  the  place  of  tlie  preceding  one  on  the  table 
of  every  medical  man,  »s  it  is  without  doubt  the  best 
and  most  eomprefiensive  work  of  the  kind  which  has 
ever  appeared. — Buffalo  Med.Xovrn.,  Jan.  1658. 

The  work  is  a  monument  of  patient  research, 
skilt'ul  judgment,  and  vast  physical  labor,  that  will 
perpetuate  the  name  of  the  author  more  effectually 
than  any  possible  d(?\'ice  of  stone  or  metal.  Dr. 
I)un!;lis<m  deserves  the  thanks  not  only  of  the  Ame- 
rican profession,  but  of  the  whole  medical  world. — 
North  Am.  Medico-Ckir.  Review,  Jan.  1653. 

A  Medical  Dictionary  better  adapted  for  the  wants 
of  the  professi(m  than  any  other  with  which  we  are 
acquainted,  and  of  a  character  which  places  it  far 
above  comparison  and  competition. — Am.  Journ. 
Med.  Sciences,  Jan.  1858. 

We  need  only  say,  that  the  addition  of  6,000  new 
terms,  with  their  accompanyin{f  definitions,  maj  be 
said  to  C(mstitute  a  new  work,  by  itself.  We  have 
examined  the  Dictionary  attentively,  and  are  most 
happy  to  pronounce  it  unrivalled  of  its  kind.  The 
erudition  displayed,  and  the  extraordinary  industry 
which  must  have  been  demanded,  in  its  preparati<m 
and  perfection,  redound  to  the  lasting  credit  of  its 
author,  and  have  furnished  us  with  a  volume  indis- 
pensable at  the  present  day,  to  all  who  would  find 
tlwemselves  au  niveau  with  the  highest  standards  of 
medical  information. — Boston  Medical  andSurgical 
Jfiurnal,  Dec.  31,  1»57. 

Good  lexicons  and  encyclopedic  works  generally, 
are  the  most  labor-saving  ccmtrivances  which  lite- 
rary men  enji)y ;  and  the  labor  which  is  required  to 
produce  them  in  the  perfect  manner  of  this  example 
IB  something  appalling  to  contemplate.    The  author 


tells  us  in  his  preface  that  he  has  added  about  six 
thousand  terms  and  subjects  to  this  edition,  which, 
before,  \vas  considered  universalh  as  the  best  work 
of  the  kind  in  any  language. — Silliman's  Journal, 
March,  1858. 

He  has  razed  his  gigantic  structure  to  the  founda- 
tions, and  remodelled  and  reconstructed  the  entire 
pile.  No  less  than  six  thousand  additional  subjects 
and  terms  are  illustrated  and  analyzed  in  this  new 
edition,  swelling  the  grand  aggregate  to  beyond 
sixty  thousand  !  Thus  is  placed  before  the  profes- 
sion a  complete  and  thorough  exponent  of  medical 
terminology ,  without  rival  or  possibility  of  rivalry. 
— Nashville  Journ.  of  Med.  and  Surg.,  Jan.  1853. 

It  is  universally  acknowledged,  we  believe,  that 
this  work  is  incomparably  the  best  and  most  com- 
plete Medical  Lexicon  in  the  English  language. 
The  amount  of  labor  which  thedistinguished  author 
has  bestowed  upon  it  is  truly  wonderful,  and  the 
learning  and  research  displayed  in  its  preparation 
are  equally  remarkable.  Comment  and  commenda- 
tion are  unnecessary,  as  no  one  at  the  present  day 
thinks  of  purchasing  any  other  Medical  Dictionary 
than  this. — St.  Louis  Med.  and  Surg.  Journ.,  Jajn. 
1858. 

It  is  the  foundation  stone  of  a  good  medical  libra- 
ry, and  should  always  be  included  in  the  first  list  of 
books  purchased  by  the  medical  student. — Am.  Med. 
Monthly,  Jan.  1858. 

A  very  perfect  work  of  ftie  kind,  undoubtedly  the 
most  perfect  in  the  English  language. — Med.  and 
SiCrg.  Reporter,  Jan.  1S58. 

II  is  now  emphatically  the  Medical  Dictionary  of 
the  English  language,  and  for  it  there  is  no  substi- 
tute.—iV.  H.  Med.  Journ.,  Jan.  1858. 

It  is  scarcely  necessary  to  remark  that  any  medi- 
cal library  wanting  a  copy  of  Dunulison's  Lexicon 
must  be  imperfect! — •Cin.  Lancet,  Jan.  1S58. 

We  have  ever  considered  it  thebes' authority  pub- 
lished, and  the  present  edition  we  may  safely  say  haa 
no  equal  in  the  world. — Peninsular  Med.  Journal, 
Jan. 1858. 

The  most  complete  authority  on  the  subject  to  te 
found  in  any  language. —  Va.Med.  Journal,  Feb.  '5fa. 


BY   THB  SAME   AUTHOR. 

THE  PRACTICE  OF  SIEDICINE.     A  Treatise  on  Special  Pathology  and  The- 
rapeutics.   Third  Edition.    In  two  largo  octavo  volumes,  leather,  of  1,50*  pages.     $S  CO. 


AND    SCIENTIFIC   PUBLICATIONS. 


13 


DUNGLISON    (R08LEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  ttie  Jefferson  Medical  College,  Philadelphia. 

HUMAN    PHYSIOLOGY.      Eighth   edition.      Thoroughly  revised   and  exten- 

sively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.     In  two  large  and 
handsomely  printed  octavo  volumes,  extra  cloth,  of  aboui  1500  pages.     f7  00. 

In  revising  this  work  for  its  eighth  appearance,  the  author  fia«  spared  no  labor  to  render  it  worthy 
a  continuance  of  the  very  great  favor  which  has  been  extended  to  it  by  the  profession.  The  whole 
contents  have  been  rearranged,  and  to  a  great  extent  remodelled  ;  the  investigations  which  of  late 
years  have  been  so  numerous  and  so  important,  have  been  carefully  examined  and  incorporated, 
and  the  work  in  every  ropect  has  been  brought  up  to  a  level  with  the  present  slate  of  the  subject. 
The  object  of  the  author  has  been  to  render  it  a  concise  but  c*:ipreheiisive  treatise,  containing  the 
whole  body  of  physiological  science,  to  which  the  student  and  man  of  science  can  at  all  times  refer 
with  the  certainty  of  finding  whatever  they  are  in  seasch  of,  fully  presented  in  all  its  aspects;  and 
on  no  former  edition  has  the  author  bestowed  more  labor  to  secure  this  result. 


We  believe  that  it  can  truly  be  said ,  no  more  com- 
plete repertory  of  tacts  upon  the  subject  treated, 
can  anywhere  be  found.  The  author  lias,  moreover, 
that  enviable  tact  at  description  and  that  facility 
and  ease  of  expression  wliich  render  him  peculiarly 
acceptable  to  the  casual,  or  the  studious  reader. 
This  faculty,  so  requisite  in  settinfj;  forth  many 
graver  and  less  attractive  subjects,  lends  additional 
charms  to  one  tilwayB  fascinating. — Boston  Med. 
mnd  Surg.  Journal. 

The  most  complete  and  satisfactory  system  of 
Physiology  in  the  English  language. — Amer.Med 
Journal . 


The  best  work  of  the  kind  in  the  English  lan- 
guage.— Silliman's  Journal. 

The  present  edition  the  author  has  made  a  perfect 
mirror  of  the  science  as  it  is  at  the  present  hour. 
As  a  work  upon  physiology  proper,  the  science  of 
the  functions  pert'orraed  by  the  body,  the  student  will 
find  it  all  he  wislies. — Nashville  Journ.  of  Med. 

That  he  has  succeeded,  mostadinirahly  succeeded 
in  his  purpose,  is  apparent  from  the  appearance  of 
an  eighth  edition.  It  is  now  the  greatencyclopaedia 
on  the  subject,  and  worthy  of  a  place  in  every  phy- 
sician's library. —  Western  Lancet. 


BY  THE  SAME  AUTHOR.     {A  new  edition.) 

aENERAL    THERAPEUTICS    AND    MATERIA  MEDICA;   adapted  for  a 

Medical  Text-book.  With  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies.  Sixth 
Edition,  revised  and  improved.  With  one  hundred  and  ninety-three  illustrations.  In  two  large 
and  handsomely  printed  octavavols.,  extra  cloth,  of  about  1100  pages.    $6  00. 


In  announcing  a  new  edition  of  Dr.  Dunglison's 
General  Tnerapeutics  and  Materia  Medica,  we  nave 
no  words  of  commendation  to  bestow  upon  a  work 
whose  merits  have  been  heretofore  so  often  and  so 
JHstly  extolled.  It  must  not  be  supposed,  however, 
that  the  present  is  a  mere  reprmt  of  the  previous 
edition;  tlie  character  of  the  author  for  laborious 
research,  judicious  analysis,  and  clearness  of  ex- 
pression, is  fully  sustained  by  the  numerous  addi- 
tions he  hiis  made  to  the  work,  and  tlie  careful  re- 
Vision  to  which  he  has  subjected  the  whole. — N.  A. 
Medico-Ckir.  Review,  Jan.  1858. 


The  work  will,  we  have  little  doubt,  be  bought 
and  read  by  the  majority  of  medical  students;  its 
size,  arrangement,  and  reliability  recommend  it  to 
ail;  no  one,  w^e  venture  to  predict,  will  study  it 
without  profit,  and  there  are  few  to  wliom  it  will 
not  be  in  some  measure  useful  as  a  work  of  refer- 
ence. The  young  practitioner,  more  especially,  will 
find  the  copious  indexes  appendtd  to  this  ediiion  of 
great  assistance  in  the  seltction  and  preparation  of 
suitable  formulae. — Charleston  Med.  journ.  and  iU- 
view,  Jan.  1858. 


BY  THE  SAME  AUTHOR.     (A  new  Edition.) 

NEW  REMEDIES,  WITH  FORMULA  FOR  THEIR  PREPARATION  AND 

ADMINISTRATION.    Seventh. edition,  with  extensive  Additions.    In  one  very  large  octavo 
volume,  extra  cloth,  of  770  pages.     f3  75. 


One  of  the  most  useful  of  the  author's  works.— 
Southern  Medical  and  Surgical  Journal. 

This  elaborate  and  useful  volume  should  be 
found  in  every  medical  library,  for  as  a  book  of  re- 
ference, for  physicians,  it  is  unsurpassed  by  any 
other  work  in  existence,  and  the  double  index  for 
diseases  and  for  remedies,  will  be  found  greatly  to 
anhance  its  value. — New  York  Med.  Gazetti. 


The  great  learning  of  the  author,  and  his  remark- 
able industry  in  pushing  his  researches  into  every 
source  whence  information  is  derivable, have  enabled 
him  to  throw  together  an  extensive  mass  of  facta 
and  statements,  accompanied  by  full  reference,  to 
authorities;  which  last  feature  renders  the  work 
practically  valuable  to  investigators  who  desire  to 
examine  tlie  original  papers. — The  American  Journal 
of  Pharmacy. 


ELLIS  (BENJAMIN).  M.D. 
THE   MEDICAL  FORMULARY :   being  a  Collection  of  Prescriptions,  derived 

from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America  and  Europe. 
Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  To  which  is  added 
an  Appendix,  on  the  Eudermie  use  of  Medicines,  and  on  the  use  of  Ether  and  Chloroform.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.  Eleventh  editioa, 
carefully  revised  and  much  extended  by  Robert  P.  Tho.'vias,  M.  D.,  Professor  of  Materia  Me- 
dica in  the  Philadelphia  College  of  Pharmacy.  In  one  volume,  8vo.,  of  about  350  pages.  $2  GO. 
(Just  Ready.) 

On  no  previous  edition  of  this  work  has  there  been  so  complete  and  thorough  a  revision.  The 
extensive  changes  in  the  new  United  States  Pharmacopoeia  have  necessitated  corresponding  alter- 
ations in  the  Formulary,  to  conform  to  that  national  standard,  while  the  progress  made  in  the 
materia  medica  and  the  arts  of  prescribing  and  dispensing  during  the  la?t  ten  years  have  been  care- 
fully noted  and  incorporated  throughout.  It  i-;  therefore  pre-ented  as  not  only  worihy  a  continuance 
of  the  lavor  so  long  enjoyed,  but  as  more  valuable  than  ever  to  the  practili.iner  and  pharmaceutist. 
Those  who  possess  previous  editions  will  find  the  additional  matter  of  sulficieat  iiupurtance  to 
warrant  their  adding  the  present  to  their  libraries. 


14 


BLANCHARD    &    LEA'S    MEDICAL 


ERICHSEN    (JOHN), 

Professor  of  Surgery  in  University  College,  London,  &c. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Surgical 

Injitries,  Diseases,  and  Operations.    New  and  improved  American,  from  the  second  enlarg-ed 

and  carefully  revised  London  edition.    Illustrated  wiih  over  four  hundred  engravings  on  wood. 

In  one  larp:e  and  handsome  octavo  volume,  of  one  thousand  closely  printed  pages,  extra  cloth, 

$5  CO;  leather,  raised  bands.     $600. 

The  very  distinguished  favor  with  which  this  work  has  been  received  on  both  sides  of  the  Atlan- 
tic has  stimulated  the  author  to  render  it  even  more  worthy  of  the  position  which  it  has  so  rapidly 
attained  as  a  standard  authority.  Every  portion  has  been  carefully  revised,  numerous  additions 
have  been  made,  and  the  most  watchful  care  has  been  exercised  to  render  it  a  complete  exponent 
of  the  most  advanced  condition  of  siKgical  science.  In  this'  manner  the  work  has  been  enlarged  by 
about  a  hundred  pages,  while  the  series  of  engravings  has  been  increased  by  more  than  a  hundred, 
rendering  it  one  of  the  most  thoroughly  illustrated  volumes  before  the  profession.  The  additions  of 
the  author  having  rendered  unnecessary  most  of  the  notes  of  the  former  American  editor,  but  little 
has  been  added  in  this  country;  some  few  notes  and  occasional  illustrations  have,  however,  been 
introduced  to  elucidate  American  modes  of  practice. 

It  is,  in  our  humble  judgment   decidedly  the  best '  step  of  the  operation,  and  not  deserting  him  until  th« 
book  of  the  kind  in  the  English  languige.    Strange  j  final  issue  of  the  case  is  decided. — Sethoscope. 
thai  just  such  books  are  notoftener  produced  by  pub-  '      Embracing,  a*  will  be  perceived,  the  whole  surgi- 
of  surgery  in  this  country  and_  Great  [  gai  domain,  and  each  division  of  it=elf  almost  eom- 
'         '  '     plete  and  perfect,  each  cbapierfull  and  explicit,  each 


lie  leach 

Briiain  Indeed,  it  is  a  matter  of  great  astonishment 
but  no  less  irue  than  a«ionisbing.  that  of  the  many 
works  on  surgery  republished  in  this  country  within 
the  last  fifieeii  or  twenty  years  as  textbooks  tor 
medical  students. this  is  the  only  one  that  even  ap- 
proximaies  to  the  fulfilment  of  the  peculiar  wants  of 
young  men  just  entering  upon  the  study  of  this  branch 
oflhe  proiession. —  Western  Jour  .of  Med.  an'l  Surgery. 

Its  value  is  greatly  enhanced  by  a  very  copious 
well-arransed  index.  We  regard  this  as  one  of  the 
most  valuable  contribulioasto  modern  surgery.  To 
one  entering  his  novitiate  of  practice,  ■we  regard  it 
the  mosi  serviceable  guide  which  he  can  consult.    He 


ubject  faithfully  exhibited,  we  can  only  express  out 
esiimate  of  it  in  the  aggregate.  Reconsider  it  an 
excellent  contribution  to  surgery,  as  probably  the 
besi  single  volume  now  exiaiii  on  the  subject,  and 
with  great  pleasure  we  add  it  to  our  text-books. — 
tfashmUe  Journal  of  Medicine  and  Surgery . 

Prof.  Erichseii's  work,  for  its  size,  has  not  been, 
surpassed;  his  nine  hundred  and  eigtii  pages,  pro- 
fusely illustrated,  are  rich  in  physiological,  patholo- 
gical, and  operative  suggestions,  doctrines,  details, 
and  processes  ;  and  will  prove  a  reliable  resource 
for  information,  boih  lo  physician  and  surseon,  in  th« 


wiU  fiud  a  fulness  of  delailleading him  thrOLgh  every  I  hour  of  peril.— iV.  O.Mtd.and  Surg.  Journal. 


FLINT  (AUSTIN),  M.   D., 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  University  of  Lonisviile,  Ac. 

PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OF  DISEASES  AFFECT- 

ING  THE  RESPIRATORY  ORGANS.     In  one  large  and  handsome  octavo  volume,  extra 
cloth,  636  pages.    $3  25. 

We  regard  it,  in  point  both  of  arrangement  and  of  }  a  work  based  upon  original  observation,  arid  pos- 
the  marked  ability  of  its  treatment  of  the  subjects,  j  sessing  no  ordinary  merit.— jY.  Y.  Journal  of  Med. 


destined  to  take  the  first  rank  in  works  of  this 
class.  So  far  as  our  information  extends,  it  has  at 
present  no  equal.  To  the  practitioner,  as  well  as 
the  student,  it  will  be  invaluable  in  clenring  up  the 
diagnosis  of  doubtful  cases,  and  in  shedding  light 
upon  difficult  phenomena. — Buffalo  Med.  Journal. 
A  work  of  original  observation  of  the  highest  merit 
We  recommend  the  treatise  to  every  one  who  wishef 
to  become  a  correct  anscultator.  Based  to  a  very 
large  extent  upon  cases  mimerieally  examined,  it 
carries  the  evidence  of  careful  stud}  and  discrimina 
tion  upon  every  pase.  It  does  credit  to  the  author 
and  through  him,  to  the  profession  in  this  country 
It  is,  what  we  cannot  call  every  book  upon  aiiscul 
tatitm,  a  readable  book. —  Am.  Jour.  Med.  Scitnee? 
This  volume  belongs  to  a  class  of  works  which 
confer  hinor  upon  tlieir  auihors  and  enrich  the  do- 
main of  practical  medicine.  A  cursory  examination 
even  will  satisfy  the  scientific  physician  that  Dr. 


This  is  an  admirable  book,  and  because  of  its  ex- 
traordinary clearness  and  entire  mastery  of  he  sub- 
jects discussed,  has  madi  itself  indispensable  to 
those  who  are  ambitious  of  a  thorough  knowledge 
of  ph\sical  exploration. — Nashville  Journ   of  Med. 

Thearrangement  of  the  subjects  discussed  is  easy, 
natural,  such  as  to  present  the  facts  in  the  most 
forcible  light.  Where  the  author  has  avoided  being 
tediously  minute  or  diffuse,  he  hasntvertheless  fully 
amplified  the  more  important  points.  In  this  re- 
spect, indeed,  his  labors  will  taise  precedence,  and 
be  the  means  of  inviting  to  this  useful  department  a 
more  general  attention. — O.  Med.  and  Surg  Journ. 

AVe  hope  these  few  extracts  taken  from  Dr.  Flint's 
work  may  convey  some  idea  of  its  character  and 
importance.  We  wf  uld,  however,  advise  every  phy- 
sician to  at  once  place  it  in  his  library,  feeling  as- 
sured that  it  may  be  consulted  with  great  benefit 


Flint  in  this  treatise  has  added  to  medical  literature  '  both  by  young  and  o\d.— Louisville  ^evieie. 
BY  THE  SAME  AUTHOR.     (Now  Ready.) 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY,  AND 

TREATMENT  OF  DISEASES  OF  THE  HEART.     In  one  neat  octavo  volume,  of  about 

500  pages,  extra  cloth.     $3  00. 

ferring  to  employ  the  very 'words  of  thedistinguished 
author,  wherever  it  was  possible,  we  have  essayed 
to  condense  into  the  briefest  space  a  general  view  of 
his  observations  and  suggestions,  and  to  direct  the 
attention  of  our  brethren  tu  the  aboundina:  stores  of 
valuable  mntter  here  collected  and  arranged  for  their 
use  and  instruction.  No  mei||cai  library-  will  here- 
after be  considered  compleie  without  this  volume; 


We  do  nof  know  that  Dr.  Flint  has  written  any- 
thing which  is  not  first  rate  ;  but  this,  his  latest  con- 
tribution to  medical  literature,  in  our  opinion,  sur- 
passes all  the  others.  The  work  is  most  comprehen- 
sive in  its  scope,  and  most  sound  in  the  views  it  enun- 
ciatis.  The  descriptions  are  clear  and  methodical ; 
the  statements  are  substantiated  by  facts,  aid  are 
made  with  such  simplicity  and  sincerity,  that  witli- 
out  them  they  would  carry  conviction.     The  style  j  and  we  trus^  it  will  promptly  find  its  way  into  the 


is  admirably  clear,  direct,  and  free  from  dryness 
Willi  Dr.  Walshe's  excellent  treatise  before  us,  we 
have  no  hesitation  in  saying  that  Dr.  Flint's  book  is 
the  best  work  on  the  heart  in  the  English  language. 
—Boston  Med.  and  Surg.  Journal 


hands  of  every  A  me' ican  student  and  physician. — 
N   Am.  Med.  Chir.  Review. 

With  more  than  pleasure  do  we  hail  the  advent  of 
this  work,  for  it  fills  a  wide  gap  on  the  list  lY  text- 
books for  our  schools,  and  is,  tor  the  practitioner, 


We  have  thus  endeavored  to  present  our  readers    the  n.ost  valuable  practical  work  of  its  kind. — li.O. 
with  a  fair  analysis  ol  this  remarkable  work.    Pre-  j  ikied.  News. 


AND    SCIENTIFIC    PUBLICATIONS. 


15 


FOWNES  (GEORGE),  PH.  D.,  Ac. 
A  MANUx\L  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and  Practical. 

With  one  hundred  and  ninety-seven  illustrations      Edited  by  Robert  Bridges,  M.  D.    In  oae 

large  royal  12mo    volume,  of  600  pages,  extra  cloth,  $1  75. 

The  death  of  the  author  having  placed  the  editorial  care  of  this  work  in  the  practised  hands  of 
Drs.  Bence  Jones  and  A.  W.  Hoflman,  everything  has  been  done  in  its  revision  which  experience 
could  suggest  to  keep  it  on  a  level  with  the  rapid  advance  of  chemical  science.  The  additions 
requisite  to  this  purpose  have  Heces^iIated  an  enlargement  of  the  page,  notwithstanding  which  the 
work  has  been  increased  by  about  fifty  pages.  At  the  same  time  every  care  has  been  used  to 
maintain  its  distinctive  character  as  a  condensed  manual  for  the  student,  divested  of  all  unnecessary 
detail  or  mere  theoretical  speculation.  The  additions  have,  of  course,  been  mainly  in  the  depart- 
ment of  Organic  Chemistry,  which  has  made  such  rapid  progi'ess  within  the  last  few  years,  but 
yet  equal  attention  has  been  bestowed  on  the  other  branches  of  the  subject — Chemical  Physics  and 
Inorganic  Chemistry — to  present  all  investigations  and  discoveries  of  importance,  and  to  keep  up 
the  reputation  of  the  volume  as  a  complete  manual  of  the  whole  science,  admirably  adapted  for  the 
learner.  By  the  use  of  a  small  but  exceedingly  clear  type  the  matter  of  a  large  octavo  is  compressed 
within  the  convenient  and  portable  limits  of  a  moderale  sized  duodecimo,  and  at  the  very  low  price 
affixed,  It  is  ofTered  as  one  of  the  cheapest  volumes  before  the  professioii. 

The  work  of  Dr.  Fowrnes  has  long-  been  before 


Dr.  Fownes' excellent  work  has  l)een  universally 
reciisnized  everywhere  in  liis  own  and  this  country, 
RB  the  best  elementary  treatise  on  chemistry  in  the 
English  tongue,  and  is  very  generally  adopted,  ^ve 
believe,  as  the  standard  text  book  in  all  <  ur  colleges, 
both  literary  and  scientific. — Charleston  Med.  Journ. 
and  Review. 

A  standard  manual,  which  has  long  enjoyed  the 
reputation  of  embodying  much  knowledge  in  a  small 
space.  The  author  hasaehieved  tlie  difficult  task  of 
condensation  with  masterly  tact.  His  book  is  con- 
cise without  being  dry,  and  brief  without  being  too 
dogmatical.or  general . —  Virginia  Med .  and  Surgical 
Journal. 


the  public,  and  its  merits  have  been  fully  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.  We  do  not,  of  course,  place  it  in  a  rank 
superior  to  the  works  of  Brande,  Graham,  Turner, 
Gregory,  or  Gmelin,  but  we  say  that,  as  a  work 
for  students,  it  is  preferable  to  any  of  them.— I,o»- 
doH  Journal  of  Medicine. 

A  work  well  adapted  to  the  wants  of  the  student. 
It  is  an  excellent  exposition  of  the  chief  doctrinea 
and  facts  of  modern  chemistry.  Thesizeof  the  work, 
and  still  more  the  condensed  yet  perspicuous  style 
in  which  it  is  written,  absolve  it  from  the  chargea 
very  properly  urged  against  most  manuals  termed 
popular. — Edinburgh  Journal  of  Medical  Scienci. 


FISKE  FUND  PRTZE  ESSAYS  —  THE  EF- 
FECTS OF  CLIMATE  ON  TUBERCULOUS 
DtpEASE.  By  RnwTN  Lee,M.R.  C  S  ,  Lond.m, 
and  THE  INFLUENCE  ( )F  PREGNANCY  ON 
THE  DEVELOPMENT  OF  TUBERCLES     By 


Edward  Warkkn,  M.  D,  of  Edenton,  N.  C.  To- 
gether  in  one  neat  8vo  volume,  extra  cloth.  81  GO. 
FRICK  ON  RENAL  AFFECTIONS;  their  Diag- 
nosis and  Pathology.  With  illustrations.  One 
volume,  royal  12mo.,  extra  cloth.    75  cents. 


FERGUSSON  (WILLIAM),  F.  R.  S., 

Professor  of  Surgery  in  King's  College,  London,  &c. 

A  SYSTEM  OF  PRACTICAL  SURGERY.     Fourth  American,  from  the  third 

and  enlarged  London  edition.    In  one  large  and  beautifully  printed  octavo  volume,  of  about  700 
pages,  with  393  handsome  illustrations,  leather.    $3  50. 


GRAHAM  (THOMAS),  F.  R.  S. 
THE  ELEMENTS  OF  INORGANIC  CHEMISTRY,  including  the  AppHca- 

tions  of  the  Science  in  the  Arts.  New  and  much  enlarged  edition,  by  Henry  Watts  and  Robert 
Bridges,  M.  D.  Complete  in  one  large  and  handsome  octavo  volume,  ol  over  800  very  large 
pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth.     $4  50. 

**^  Part  II.,  completing  the  work  from  p.  431  to  end,  with  Index,  Title  Matter,  &c.,  may  be 
had  separate,  cloth  backs  and  paper  sides.     Price  $2  50. 


From  Prof.  E.  N.  Horsford,  Harvard  College. 

It  has,  in  its  earlier  and  less  perfect  editions,  been 
familiar  to  me,  and  the  excellence  of  its  plan  and 
the  clearness  and  completeness  of  its  discussions, 
have  long  been  ray  admiration. 

No  reader  of  EniJ-lish  works  on  this  science  can 


afford  to  be  without  this  edition  of  Prof.  Graham'* 
Elements. — Silliman\i  Journal,  M.aTch,  1S58. 

From  Prof.  Wolcott  Gibbs,  N.  Y.  Free  Academy. 

The  work  is  an  admirable  one  in  all  respects,  and 
its  republication  here  cannot  fail  to  exert  a  positive 
influence  upon  the  progress  of  science  m  this  country. 


GRIFFITH  (ROBERT  E.),  M.  D.,  «tc. 
A  UNIVERSAL  FORMULARY,  containing  the  methods  of  Preparing  and  Ad- 

ministering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceu- 
tists. Second  Edition,  thoroughly  revised,  with  numerous  additions,  by  Robert  P.  Thomas, 
M.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large  and 
handsome  octavo  volume,  extra  cloth,  of  650  pages,  double  columns,     $3  50. 

This  is  a  work  of  six  hundred  and  fiftj'-one  pages, 
embracing  all  on  the  subject  of  preparing  and  admi- 
iiislering  medicines  that  can  be  desired  by  the  physi- 
fiian  and  pharmaceutist. —  Western  Lancet. 

The  amountof  useful, every-day  matter, for  a  prac- 
ticing physician,  is  really  immense. — Boston  Med. 
and  Surg.  Journal. 


It  was  a  work  requiring  much  perseverance,  and 
when  published  was  looked  upon  as  by  far  the  besi 
work  of  its  kind  that  had  issued  from  the  American 
press.  Prof  Thomas  ha.s  certainly  "improved."  a? 
well  as  added  lolhis  Formulary,  and  has  rendered  it 
additionally  deserving  of  the  confidence  of  pharma- 
ceutists and  physicians. — Atk.  Journal  of  Pharmacy . 

We  are  happy  to  announ(;e  a  new  and  improved 
edition  of  this,  one  of  the  most  valuable  and  useful 
works  that  have  emanated  from  an  American  pen. 
It  would  do  credit  to  any  country,  and  will  be  found 
of  daily  usefulness  to  practitioners  of  medicine;  it  is 
better  adapted  to  their  purposes  than  the  dispensato- 
ries.— Southern  Med.  and  Surg.  Journal. 

Itis  one  oftlie  most  useful  hooks  a  country  practi 
Uoner  can  possibly  have. — Medical  Chroniclt.  . 


This  edition  has  been  greatly  improved  by  the  re- 
vision and  ample  additions  of  Dr  Thomas,  and  is 
now,  we  believe,  one  of  the  mosi  complete  works 
of  its  kind  in  any  language.  The  additions  amount 
to  aboutsevenly  pages,  and  no  efTorl  has  been  spared 
to  include  in  them  all  the  recent  improvements.  A 
work  of  this  kind  appears  to  us  indispensable  to  the 
physician,  and  there  is  none  we  can  more  cordially 
recommend. —  N.  Y.  Journal  of  Medieint. 


16 


BLANCHARD   &    LEA'S   MEDICAL 


1 


GROSS  (SAMUEL  D.),   M.  D., 

Professor  of  Surpery  in  the  Jefferson  Medical  College  of  Philadelphia,  &e. 
Enlarged  Edition,    Preparing  for  early  publication. 

A  SYSTEM  OF  SURGERY  :  Pathological,  Diagnostic,  Thorapeutic,  and  Opera- 
tive. Illustrated  by  over  Twelve  Hundrkd  Engravings.  Third  edition,  much  enlarged  and 
careluUy  revised.   In  two  large  and  beautifully  printed  royal  octavo  volumes.     (In  Press.) 

The  exhaiii^tion  wiihin  five  years  of  two  large  editions  of  so  elaborate  and  comprehensive 
a  woik  as  this  is  the  best  evidence  that  the  author  was  not  mistaken  in  his  estimate  of  the 
wani  which  existed  of  a  complete  American  System  of  Surgery,  presenting  the  science  in  all  \\^ 
necessary  de'ails  and  in  all  its  branches.  That  he  has  succeeded  in  the  attempt  to  supply  this  want 
is  shown  not  only  by  the  rapid  sale  ol  the  work,  but  also  by  the  very  favorable  manner  in  which  it 
has  been  received  by  the  organs  of  the  profes^ion  in  this  country  and  in  Europe,  and  by  the  fact  that 
a  tran^lalion  is  now  preparing  in  Holland — a  mark  of  appreciatioa  not  often  bestowed  on  any  scien- 
tific work  so  extended  in  size. 

The  author  has  not  been  insensible  to  the  kindness  thus  bestowed  upon  his  labors,  and  in  revising 
the  woik  for  a  third  edition  he  has  spared  no  pains  to  renrler  it  worthy  ot  the  favor  with  which  it 
has  been  received.  Every  portion  has  been  subjected  to  close  examination  and  revision  ;  any  defi- 
ciencies apparent  have  been  supplied,  and  the  results  of  recent  progress  in  the  science  and  r.rt  o< 
surgery  have  been  everyvvliere  introduced;  while  the  series  of  illustrations  has  been  still  further 
enlarged,  rendering  it  one  of  the  most  thoroughly  illustrated  works  ever  laid  before  the  profession. 
To  accommodate  these  very  extensive  additions,  the  form  of  the  work  will  be  altered  to  a  royal 
octavo,  so  that  notwithstanding  the  increase  in  the  maltei  and  value  of  the  book,  its  size  wi  I  be  found 
more  convenient  than  before.  Every  care  will  betaken  in  the  printing  to  render  the  typographical 
execution  unexceptionable,  and  it  is  confidently  expi^cted  to  prove  a  work  iu  every  way  worthy  of 
a  place  in  even  the  most  limited  library  of  tht   piaclitioner  or  student. 


Has  Dr.  Gross  satisfactorily  fulfilled  this  object? 
A  caieful  perusal  of  his  volumes  enubles  us  to  give 
an  answer  in  the  affirms  live.  Not  only  has  he  given 
to  the  reader  an  elaooriite  and  well- written  account 
of  his  o>vn  va^t  experience,  but  he  has  not  failed  to 
embody  in  his  pages  the  opinions  and  practice  of 
surgeons  in  this  and  other  countries  of  Europe.  The 
result  has'been  a  work  of  such  completeness,  that  it 
has  no  superior  in  the  systematic  trearises  on  sur- 
gery which  have  emanated  from  English  or  Conti- 
nental authors.  It  has  been  justly  objected  that 
these  have  been  far  from  complete  in  many  essential 
particulars,  mnny  of  them  havin?  been  deficient  in 
some  of  the  most  important  points  whieh  should 
characterize  such  works  Some  ol  them  have  been 
elaborate — too  elHborate— wiih  respect  to  certain 
diseases,  while  they  have  merely  ghinced  at,  or 
given  an  unsatisfactory  account  of,  others  equally 
important  to  the  surgeon.  Dr.  Gross  has  avoided 
this  error,  and  has  produced  the  most  complete  work 


Of  Dr.  Gross's  treatise  on  Surgery  we  can  say 
no  more  than  that  it  is  the  most  elaborate  and  com- 
plete work  on  this  branch  of  tht  healing  art  whieh 
lias  ever  been  published  in  any  country.  A  sys- 
tematic work,  it  admits  of  no  analytical  review; 
but,  did  our  space  permit,  we  should  gladly  give 
some  extracts  from  it,  to  enable  our  readers  to  judge 
of  the  c'assieal  style  of  the  author,  and  the  exhaust- 
ing way  in  which  each  subject  is  treated. — DAi/i» 
Quarterly  Journal  of  Med.  Science. 

The  work  is  so  superior  to  its  predecessors  in 
matter  and  extent,  as  well  as  in  illustrations  and 
style  of  publication,  that  we  can  honestly  recom- 
n^end  it  as  the  best  work  of  the  kind  to  be  taken 
home  by  theyoiing  practitioner. — Atn.  Med.  Journ. 

With  pleasure  we  record  the  comp'etion  of  this 
long-anticip!  ted  work.  The  reputation  which  the 
author  has  for  many  years  sustained,  both  as  a  sur- 
geon and  as  a  writer,  had  prepared  us  to  expect 


of  surgical  diseases.    Having  said  so  much,  it  might  |  country,  and  we  might,  perhnps    safelv  say,  the 
appear  superfluous  to  add  another  w  .rd  ;  but  it  is  I  most  original.     Ther.  is  no  subject  belonging  pro- 


perly to  surgery  wl.ich  has  not  received  from  the 
uuthoi  a  due  share  of  attention.  Dr.  Grots  has  sup- 
plied a  want  in  surgical  literature  wliich  has  long 
been  felt  by  practitioners;  he  has  furnished  us  with 
a  complete  practical  treatise  upon  surgery  in  all  its 
departments.  As  A  neric  ins,  we.  are  proud  of  the 
achievement;  as  surgeons,  we  are  most  sincerely 
thankful  to  him  for  his  extraord  nary  labors  in  oul 
behalf. — N.  Y.  Review  and  Buffalo  Med.  Journal, 


appear  supt 

only  due  to  Dr.  Gro5s  to  state  that  he  has  embraced 
the  opportunity  of  transferring  to  his  pages  a  vast 
number  o(  engravings  from  English  and  other  au- 
thors, illustrative  01  the  paihology  and  treatment  of 
surgical  diseases.  To  these  arc  added  several  hun 
dred  original  wood-cuts.  The  work  altogether  com- 
mends itself  to  the  attention  of  Britibli  surgeons, 
from  whom  it  cannot  fail  to  meet  with  extensive 
patronage. — London  Lancet,  Sept.  1,  IStiO. 

BY  THE  SAIVIE  AUTHOR. 

ELEMENTS  OF  PATHOLOGICAL  ANATOMY.     Third  edition,  thoroughly 

revi>^ed  and  greatly  improved.  In  one  large  and  very  handsome  octavo  volume,  with  about  three 
hundred  and  fifty  beautiful  illustrations,  of  which  a  large  number  are  from  original  drawings, 
extra  cloth.    f4  75.  :,     .      .v.    ,     .  r  i. 

The  very  rapid  advances  in  the  Science  of  Pathological  Anatomy  during  the  last  few  years  have 
rendered  essential  a  thorough  modification  of  this  work,  with  a  view  of  making  it  a  correct  expo- 
nent of  the  present  state  of  the  subject.  The  very  careful  manner  in  which  this  task  has  been 
executed,  and  the  amount  of  alleration  which  it  has  undergone,  have  enabled  the  author  to  say  that 
'<  with  the  many  changes  and  improvements  now  introduced,  the  work  may  be  regarded  almost  as 
anew  treatise,"  while  the  efforts  of  the  author  have  been  seconded  as  regards  the  mechanical 
execution  of  the  volume,  rendering  it  one  of  the  handsomest  productions  of  the  American  press. 
We  most  sincerely  congratulate  the  author  <m  the  ,      We  have  .''f'''n^f'»Y"^'i^U'ATf  l?f  ^^^!!!l.'.''v,';Ffrfj 


successful  manner  in  which  he  has  accomplished  his 
proposed  object.  His  book  is  most  admirably  cal- 
culated to  fill  up  a  blankwhich  has  long  beenfelt  to 
exist -in  this  department  of  medical  literature,  and 
as  such  must  become  very  widely  circulated  amongst 
all  classes  of  the  profession.  —  Dufc/i«  Quarterly 
Journ.  of  Med.  Science,  Nov.  1857. 


ral  manner  in  which  Dr.  Gross  hasexecuted  his  task 
of  affording  a  comprehensive  digest  of  the  present 
state  of  the  literature  of  Pathological. Anatomy,  and 
have  much  pleasure  in  recommending  his  work  to 
our  readers,  as  we  believe  one  well  deserving  of 
diliijent  perusal  and  careful  stxidy  .—Montreal  M»d. 
CAron.,  Sept.  1857. 
BY  THE  SAME  AUTHOR. 


A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIE-PAS- 

SAGES.    Inonehandsomeoctavovolume,  extra  cloth,  with  illuslratious.    pp.  4tJS.    $2  75. 


AND    SCIENTIFIC  PUBLICATIONS 


17 


GROSS  (SAMUEL   D.),   M.D., 
Professor  of  Surgery  in  the  Jefferson  iMedical  College  of  Philadelphia,  Sec. 

A   PRACTICAL    TREATISE   ON    THE    DISEASES,    INJURIES,  AND 

MALFORMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND,  AND 
THE  URETHRA.  Second  Edition,  revised  and  much  enlarged,  with  one  hundred  and  eighty- 
four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine  hundred  pages, 
extra  cloth,  $4  7-5. 

Philosophical  in  its  design,  methodical  in  its  ar-  I  as:ree  v.'ith  us,  that  there  is  no  work  in  the  English 
rangement, ample  and  sound  in  its  practical  details,  '  lan^uapfe  which  can  make  any  just  pretensions  to 
it  may  in  truth  be  said  to  leave  scarcely  anything  to  :  he  its  equal. —  N.  Y.  Journal  of  Medicine . 
be  desired  on  so  important  a  subject.— Bo5<o»  ATed.        A  volume  replete  with  truths  and  principles  of  the 
and  Sure  Journal.  •  atmost  value  in  the  investigation  of  these  diseases. — 

Whoever  will  peruse  the  vast  amount  of  valuable    American  MedicalJournal . 
practical  information  it  contains,  will,  we  think,! 


GRAY  (HENRY),   F.  R.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London,  &fi. 

ANATOMY,  DESCRIPTIVE  AND   SURGICAL.      The  Drawings  by  H.  V. 

Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissections  jointly 
by  the  Author  and  Dr.  Carter.  Second  American,  from  the  seond  revised  and  improved 
London  edition.  In  one  magnificent  imperial  octavo  volume,  of  over  800  pages,  with  3S8  large 
and  elaborate  engravings  on  wood.     Price  in  extra  cloth,  $7  00. 

The  speedy  exhaustion  of  a  large  edition  of  this  work  i.s  sutRcient  evidence  that  its  plan  and  exe- 
cution have  been  found  to  prestnt  superior  practical  advantages  in  facililaling  the  study  ol  Anato- 
my. In  presenting  it  to  the  profession  a  second  time,  the  auttior  has  availed  himself  of  the  oppo"-- 
tuiiity  to  supply,  any  deficiencies  which  experience  in  its  use  had  shown  to  exist,  and  to  correct 
any  errors  of  deiail,  to  which  the  first  edi'ion  ol  a  scientific  work  on  so  extensive  and  complicated 
a  science  Is  liable.  The>e  improvements  have  resulted  in  some  increase  in  the  size  of  the  volume, 
■while  twenty-six  new  wood-cnt*  have  been  added  to  the  beautiful  series  of  illustrations  which 
form  so  distinctive  a  feature  of  the  work.  The  American  edition  ha*  been  passed  through  the  press 
under  the  supervision  of  a  competent  professional  man,  who  has  taken  every  care  to  render  it  in 
all  respects  accurate,  and  it  is  now  presented,  without  any  increase  of  price,  as  fitted  to  maintain 
and  extend  the  popularity  which  it  has  everywhere  acquired. 


With  little  trouble,  the  busy  practitioner  whose 
knowledge  of  anatomy  miiy  have  become  obscured  by 
want  of  practice,  may  now  resuscitate  his  former 
anatomical  lore,  and  be  ready  for  any  emergency. 
It  is  to  this  class  of  individuals,  and  not  to  the  stu- 
dent alime,  that  this  \vrirk  will  ultimately  tend  to 
be  of  most  incal  !ulablp  ad  vantage,  and  we  feel  sat- 
isfied that  the  library  of  the  medical  man  w^ili  socm 
be  considered  incomplete  in  winch  a  cooy  of  this 
work  does  not  exist.-  Madras  Quarterly  Journal 
of  Med.  Science,  July,  1661. 

This  edition  is  much  improved  and  enlarged,  and 
contains  several  new  illustrations  by  Dr.  Westma- 
cott.  The  volume  is  a  complete  companion  to  the 
dissecting-room,  and  saves  the  necessity  of  the  stu 
dent  possessing  a  variety  of"  Manuals." — The  Lon- 
don Lancet,  Feb.  9,  1861. 

The  work  before  us  is  one  entitled  to  the  highest 
praise,  and  we  accordingly  welcome  it  as  a  valu- 
able addition  to  medical  literature.  Intermediate 
in  fulness  of  detail  between  the  treatises  of  S  lar- 
pey  and  of  Wilson,  its  cliarncterisric  merit  lies  in 
the  number  and  excellence  of  the  engravings  if 
contains.  Most  of  these  are  original,  of  much 
larger  than  ordinary  size,  and  adniirab;y  executed 
The  various  parts  are  also  letlered  after  the  plan 
adopted  in  Holden's  Osteology.  It  would  be  aiffi- 
cult  to  over-estimate  the  advantages  offered  by  this 
mode  of  pictorial  illusiration.  Bones,  ligaments, 
muscles,  bloodvessels,  and  nerves  are  each  in  turn 


work  of  Mr.  Gray  to  the  attention  of  the  medical 
profession,  feeling  certain  tiiat  it  should  be  regarded 
as  one  of  the  most  valuable  contrioutions  ever  made 
to  educational  literature. — N.  Y.  Monthly  Review. 
Dec.  1859. 

In  this  vie^v,  we  regard  the  work  of  Mr.  Gray  as 
far  better  adapted  to  the  wants  of  the  profession, 
md  especially  of  the  student,  than  any  treaiise  ou 
tnatomy  yet  published  in  this  country.  It  is  destined, 
ive  believe,  to  supersede  ill  others,  both  as  a  manual 
of  dissections,  and  a  standard  of  reference  to  the 
student  of  general  or  relative  anatomy.  —  N.  Y. 
Journal  of  Medicine,  Nov.  1859. 

In  our  judgment,  the  mode  of  illustration  adopted 
in  the  present  volum;  cannot  but  present  many  ad- 
vantages to  the  student  of  anatomy.  To  the  zealous 
disciple  of  Vesalius,  earnestly  desirous  of  real  im- 
provement, the  book  w^iU  certainly  be  of  imm-.nse 
value;  but,  at  the  same  time,  we  must  also  confes.s 
fhat  to  those  simply  desirous  of  "cramming"  it 
will  bean  undoubted  godsend.  The  peculiar  value 
of  Mr.  Gray's  mode  of  illustration  is  nowhere  more 
markedly  evident  than  in  the  chapter  on  osteology, 
and  especially  in  those  portions  which  treat  of  the 
bones  of  the  head  and  of  Ihiir  development.  The 
study  of  these  parts  is  thus  made  one  of  comparative 
ease,  if  not  of  positive  pleasure ;  and  those  bugbears 
of  the  student,  the  temporal  and  sphenoid  bones,  are 
shorn  of  ha'f  their  terrors.     It  is,  in  our  estimation, 


figured,  and  marked  with  their  appropriate  names;  an  admirable  and  complete  text-book  for  the  student, 
thus  enabling  the  student  to  C(  mprehend^ata  glance,  i  and  a  useful  work  of  reference  for  the  practitioner; 
what  would  otherwise  often  he  ignored,  or  at  any  '  its  pictorial  character  forming  a  novel  element,  to 
rate,  acquired  only  by  prolonged  and  irksome  ap-  i  which  we  have  already  sufficiently  alluded. — Am. 
plication.     In  conclusion,  we  heartily  commend  the  '  Joum.  Med.  Sci.,  July,  18.59. 


GIBSON'S  INSTITUTES  AND  PRACTICE  OF 
SURGERY.  Eighth  edition,  improved  and  al- 
tered. With  thirty-fourplates.  In  twohandsome 
octavo  volumes,  contain  ng  about  1,000  pages, 
leather,  raised  band  I.     S6  ."iO. 

GARDNER'S  MEDICAL  CHEMISTRY,  for  the 
use  of  Students  and  the  Profession.  In  one  roya] 
12mo.  vol.,  cloth,  pp.  396,  with  wood  cuts.    SI. 

GLUGE'S  ATLAS  OF  PATHOLOGICAL  HIS- 
TOLOGY Translated,  with  Notes  and  Addi- 
tions by  Joseph  Leidy,  iSl.  D.  In  one  volume 
very  large  impmal  quarto,  extra  cloth,  wit'i  32( 
copper-  plate  figures,  plain  and  colored,   $5  00. 

HUGHES'  INTRODUCTION  TO   THE  PRAC- 


TICE OF  AUSCULTATION  AND  OTHER 
MODES  OF  PHYSICAL  DIAGNOSIS  IN  DIS- 
EASES OF  THE  LUNGS  AND  HEART.     Se- 

cond  edition  1  vol.  royal  12mo.,  sx.  cloth,  pp. 
304      91  00. 

HOLLAND'S  MEDICAL  NOTES  AND  RE- 
FLECTIONS. From  the  third  London  edition. 
In  one  handsome  octavo  volume,  extra  cloth.  $-3. 

HORNF.R'S  SPFCIAL  ANATOMY  ANO  HiS- 
TOI-OGY.  Eiffhlh  edition.  Extensively  revised 
and  moriitied.  In  two  large  octavo  volumes,  ex- 
tra cloth,  of  more  than  1000 pages,  with  over  300 
illuscrations.    $6  00. 


18 


BLANCHARD   &    LEA'S    MEDICAL 


HAMILTON  (FRANK    H.),    M.   D., 

Professor  of  Sursjery  in  the  I>nn<^  Islanil  College  Hospital. 

A  PRACTICAL   TREATISE    ON   FRACTURES   AND   DISLOCATIONS. 

Second  edition,  revised  and  improved.     In  one  iare-e  and  handsome  octavo  volume,  of  over  750 
page.*,  with  nearly  300  iiiusiratioiis,  extra  cloth,  |4  7.^.     {Just  Ready,  May,  lS6i.) 

The  earlv  demand  for  a  new  edition  of  this  work  shows  that  it  has  been  sncce-isfiil  in  securing 
the  confidf'nce  of  the  profession  as  a  standard  authority  for  consultation  and  reference  on  its  im|)ort- 
ant  and  difficult  subject.  In  fgain  passing  it  ihrous'h  the  press,  the  anihor  has  taken  the  opportu- 
nity to  revi.-^e  it  carefully,  and  introduce  ■whatever  improvements  have  been  suggested  by  further 
experie.nce  and  observation  An  additional  chapter  on  Gun-shot  Fractures  will  be  found  to  adapt 
it  still  more  t'ully  to  the  exigencies  of  the  time.  • 


Amons  the  many  good  workers  at  surgery  of  whom 
Ameriea  may  now  Hon  st  rot  the  le^pt  is  Frank  Hast- 
ings Hamilton^  and  the  volume  before  us'S  (we  say 
it  wi'h  a  pang  of  wounded  patriotism)  the  hest  and 
handiest  book  on  tne  subject  in  the  Eiglish  lan- 
%n»^e.  It  is  in  vain  to  attempt  a  review  of  it; 
nearly  as  vain  to  seek  for  any  S'ns,  either  of  com- 
mission or  omission.  We  have  seen  no  work  on 
practical  surgery  which  we  would  sooner  recom- 
menil  to  our  brother  surgeons,  especially  those  of 
''  the  services,"  i  r  those  whose  practice  lies  in  dis- 
tricts wliere  a  man  has  necessarily  to  rely  on  tiis 
own  unaided  resources  The  practitioner  will  find 
in  It  directions  for  nearly  every  possible  acJiOent, 
easily  fi>und  and  comprehended  ;  and  much  pleasant 
reading  for  him  to  muse  over  in  the  after  considera- 
tion of  his  cases. — Edinburgh  Med.Journ.  Feb.  1661. 

This  is  a  valuable  contribution  to  the  surgery  of 
most  important  afrectinnE,anu  is  the  moreweleome, 
inasmuch  as  at  tne  present  time  we  do  not  possess 
a  single  complete  treatife  on  Fractures  and  Dislo- 
cafionsin  the  Knslish  language.  It  hasremained  for 
our  American  brother  to  produce  a  complete  treatise 
upon  the  subject,  and  bring  together  in  a  convenient 
form  those  alterations  and  improvement^  that  have 
been  made  from  time  to  lime  in  the  treatment  of  these 
affections.  One  great  and  valuable  feature  in  the 
work  before  us  is  the  fact  that  it  comprises  all  the 
Improvements  introduced  into  the  practice  of  both 
Kiiglish  and  American  surgery,  and  though  far  from 
omitting  mention  of  pur  continental  neighbors,  the 
author  by  no  means  (ncourages  the  notion — but  too 
prevalent  in  some  quarters— that  nothing  is  good 
unless  imported  from  France  or  Germany.  Tne 
latter  half  of  the  work  is  devoted  to  the  considera- 
tion of  the  various  dislocations  and  their  appropri- 
ate treatment,  and  its  merit  is  fully  equal  to  that  of 
tlie  preceding  portion. —  The  London  Lancet, Mu.y  5, 
1860. 

It  is  emphatically  the  book  upon  the  subjects  of 
which  it  treats,  and  we  cannot  doubt  that  it  will 
continue  so  to  be  for  an  indefinite  period  of  time. 


When  we  say,  however,  that  we  believe  it  will  at 
(mee  take  us  place  as  the  best  book  for  consultation 
by  the  practitioner;  and  that  it  will  form  the  most 
complete,  available,  and  reliable  guide  in  emergen- 
cies of  ever>  nature  cimneeted  with  its subjt-cts;  and 
also  that  the  student  of  surgery  may  make  it  his  text- 
book with  entire  confidence,  and  with  pleasure  also, 
from  its  agree  ible  and  easy  style — we  ihink  our  own 
opinion  may  be  gathered  as  to  its  value. —  floston 
Medical  and  Surgical  Journal,  March  1,  I860. 

The  work  is  concise,  judicious,  and  accurate,  and 
adapted  to  the  wants  of  the  student,  practiticner, 
and  investigator,  honorable  to  the  author  and  to  the 
profession. — Chicago  Med.  Journal,  March,  1860. 

We  rerard  this  work  as  an  honor  not  only  to  its 
author,  but  to  the  protession  of  our  country.  Were 
we  to  reviewit  thoroughly,  we  could  not  convey  to 
the  mini!  of  ihe  reader  more  forcibly  our  honest 
opinion  expressed  in  the  few  words — we  think  it  the 
oest  book  ol  its  kind  extant.  Every  man  interested 
in  Burgerj  will  soon  have  this  work  on  his  desk. 
He  who  does  not,  will  be  the  loser. — New  Orleans 
Medical  ^ew-s  March.  1860. 

Dr.  Hamilton  is  fortunate  in  having  succeeded  in 
filling  the  void,  so  long  felt,  w^ilh  what  cannot  fail 
to  be  at  once  accepted  as  a  model  monograph  in  some 
respects,  and  a  work  of  classicil  authority.  We 
sincerely  congratulate  the  profession  of  the  Urited 
States  on  tlie  appearanee  of  such  a  publication  from 
one  of  their  number.  We  have  reason  to  be  proud 
of  it  as  an  original  work,  both  in  a  literary  and  s  -i- 
entific  point  of  view,  and  to  esteem  it  as  a  valuable 
guide  in  a  most  difficult  and  important  branch  of 
study  and  practice.  On  every  account,  therefore, 
we  hope  that  it  may  soon  be  widely  known  abroad 
as  an  evidenee  of  genuine  progress  on  this  side  of 
the  Atlantic,  and  further,  that  it  may  be  still  more 
widely  known  at  home  as  an  aiithoritative  teacher 
from  which  evtry  one  may  profitably  learn,  and  as 
affording  an  example  of  honest,  well-directed,  and 
untiring  industry  in  authorship  which  every  surgeoa 
may  eniulate.-  Am.  Med.  Journal,  April,  1860. 


HODGE  (HUGH    L.),   M.  D., 

Professor  of  Midwifery  and  the  Diseases  of  VVomen  and  Children  in  the  University  of  Pennsylvania,  &c. 

ON   DISEASES   PECULIAR   TO  WOMEN,  including  Displacements  of  the 

Uterus.     With  original  illustrations.     In  one  beautifully  printed  octavo  volume,  of  nearly  500 
pages,  extra  cloth,     f  3  25. 


We  will  say  at  once  that  the  work  fulfils  its  object 
capitally  well  J  and  we  will  moreover  venture  the 
assertion  that  it  will  inaugurate  an  imoroved  prac- 
tice throughout  this  whole  country.  The  secretsof 
the  author's  success  are  so  clearly  revealed  that  the 
attentive  student  cannot  fail  to  insure  a  goodly  por- 
tion of  similar  success  in  his  own  practice.  It  is  a 
credit  to  all  medical  literature;  and  we  add,  that 
the  ph.ysician  who  does  not  place  it  in  his  library, 
and  who  does  not  faithfully  con  its  pages,  will  lose 
a  vast  deal  of  knowledge  that  would  be  most  uset'ul 
to  himself  and  beneficial  to  liis  patients.  It  is  a 
practical  work  of  the  highest  order  nf  merit;  and  it 
will  lake  rankas  such  immediatelv. — Marylandand 
Virginia  Medical  Journal,  Feb.  1861. 

This  contribution  towards  the  elucidation  of  the 
pathology  and  treatment  of  some  of  the  diseases 
peculiar  to  women,  cannot  fail  to  meet  with  a  favor 
able  reception  from  the  medical  profession.  The 
character  of  the  particular  maladies  of  which  the 
work  before  us  treats;  their  frequencj  ,  variety,  and 
obscuiity;  theamountot  malaiseand  even  of  actual 
sutTering  by  which  they  are  invanibly  attended; 
their  obstinacy,  the  difficulty  wilh  which  they  are 
overcome,  and  their  disposition  again  and  again  to 


recur — these,  taken  in  connection  with  the  entire 
competency  of  the  author  to  render  a  correct  ac- 
count of  their  nature  their  causes,  and  their  appro- 
priate management — his  ample  experience,  his  ma- 
tured judgment,  and  his  perfect  conscientiousness — 
invest  this  publication  with  an  interest  and  value  to 
which  few  of  the  medical  treatises  of  a  recent  aate 
can  lay  a  sir(mger,  if,  perchance,  an  equal  claim. — 
Am.  Journ.  Mid.  Sciences,  Jan.  1861. 

Indeed,  alth(mgh  no  part  of  the  volume  isnotemi- 
nently  deserving  of  perusal  and  study,  we  think  that 
the  nine  chaptt  rs  devoted  to  this  subject,  are  espe- 
ciallv  so,  and  wt  know  of  no  more  valuable  mimo- 
graph  upon  the  symptoms,  prognosis,  and  manage- 
ment of  these  annoying  maladies  than  is  conttituted 
by  this  part  of  the  work.  We  cannot  but  regard  it 
as  one  of  the  most  original  and  m  >st  practical  worKs 
of  the  (lay;  one  which  every  accoucheur  and  physi- 
ciaa  should  most  carefully  re  id ;  for  we  are  per- 
suaded that  he  will  arise  from  its  peiusal  with  new 
ideas,  which  will  induct  him  into  a  more  rational 
practice  in  regard  to  many  a  sufTering  t'emile,  who 
may  have  placed  iier  health  in  his  hands. — British 
American  Journal,  Feb.  It6l. 


The  illustrations,  which  are  all  original,  are  drawn  to  a  uniform  scale  of  one-half  the  natural  size. 


AND    SCIENTIFIC    PUBLICATIONS.  19 

HODGE  (HUGH    L.),    M.  D.. 

Late  Professor  of  Mi  Iwifery,  &c..,  in  the  University  of  Pennsy^cania. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.     In  one  lars^e  quarto 

volume  ofo/er  550  pfges,  with  one  hundred  and  (ifty-eight  figures  on  ihirly  two  beautifully  exe- 
cuted lithographic  plates,  and  numerous  wood-cuts  in  the  text.  $13  00  {Now  Ready.) 
This  work,  embodying  the  results  of  an  extensive  practice  for  more  than  forty  years,  cannot  fail 
to  prove  of  the  utmost  value  to  all  who  are  engaged  in  this  department  of  medicine.  The  author's 
position  as  one  of  ihe  highest  anthnriiies  on  the  subject  in  this  country  is  well  known,  and  the  fruit 
of  his  ripe  experience  and  long  observation,  carefully  matured  and  elaborated,  must  serve  as  an 
iiivaUiable  text-book  for  the  student  and  an  unfailing  counsel  for  the  practitioner  in  the  emergencies 
■which  so  frequently,  arise  in  obstetric  practice. 

The  illustrations  will  form  a  novel  feature  in  the  work.  The  lithographic  plates  are  all  original, 
and  to  insure  their  absolute  accuracy  they  have  all  been  copied  from  photographs  taken  expressly 
for  the  purpose.  In  ordinary  obstetrical  plates,  the  positions  of  the  foetus  are  represented  bv  dia- 
gram-* or  sections  of  the  patient,  which  are  of  course  purely  imaginary,  and  their  correctness  is 
scarcely  more  than  a  matier  of  chance  with  the  artist.  Their  beauty  as  pictures  is  thereby  increased 
without  corresponding  utility  to  the  stuilent,  as  in  practice  he  must  for  the  most  part  depend  for  his 
diagnosis  upon  the  relative  positi<ins  o(  the  fcEial  skull  and  the  pelvic  bones  of  the  mother.  It  is, 
therefore,  desirable  that  the  points  upon  which  he  is  in  future  to  rely,  shou'd  form  the  basis  of  hi-s 
instruction,  and  consequently  in  the  preparation  of  the>e  illustrations  the  skeleton  has  alone  been 
used,  and  the  aid  of  photography  invoked,  by  which  a  series  of  represenlalioiis  has  been  secured  of 
the  strictest  and  most  rigid  accuracy.  It  is  easy  to  recognize  the  value  thus  added  to  the  very  full 
detai  s  on  the  subject  of  the  Mkchanism  of  Labour  with  which  the  work  abounds 

it  may  be  added  that  no  pains  or  expen.se  will  be  spared  to  render  the  mechanical  execution  of  the 
volume  worthy  ia  every  respect  of  the  character  and  value  of  the  teachings  it  contains. 


HABERSHON  (S.  O.),  M.  D., 

Assistant  Physician  to  and  Lecturer  on  Materia  JVIedica  and  Therapeutics  at  Guy's  Hospital,  &c. 

PATHOLOGICAL   AND    PRACTICAL  OBSERVATIONS  ON  DISEASES 

OF  THE  ALIMEXTARY  CANAL,  CESOPHAGUS,  STOMACH,  C-ECUM,  AND  INTES- 
TINES. With  illustrations  on  wood.  In  one  handsome  octavo  volume  of  312  pages,  extra 
cloth     $2  CO. 


HOBLYN  (RICHARD  DJ,  M.  D. 
A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND  THE 

COLLATERAL  SCIENCES.     A  new  American  edition.     Revised,  with  numerous  Additions, 
by  Isaac  Hays,  M.  D.,  editor  of  the  "  American  Journal  of  the  Medical  Sciences."    In  one  large 
royal  l2mo.  volume,  leather.of  over  500  double  columned  pages.     $1  75. 
To  both  practitioner  and  student,  we  recommend  ]  use  ;  embracing  every  department  of  medical  scienca 

this  dictionary  as  being  convenient  in  size,  accurate 

in  definition,  and  sufficiently  full  and  complete  for 

ordinary  consultation. — C karleston  Med.  Journ. 
We  know  of  no  dictionary  better  arranged  and 

adapted.  Itisnotencumbered  wilh  theobsoletelerins 

of  a  bygone  age,  but  it  contains  all  that  are  now  in 


down  to  the  very  latest  date.  —  Western  Lancet. 

Hoblyn's  Dictionary  has  long  been  a  favorite  with 
us.  It  is  the  best  book  of  definitions  we  have,  and 
ought  always  to  be  upon  the  student's  table. — 
Soutkern  Med.  and  iHurg .  Journal . 


JONES  (T.   WHARTON),   F.  R.  S., 

Professor  of  Ophthalmic  Medicine  and  Surgery  in  University  College,  London,  &;c. 

THE   PRINCIPLES  AND   PRACTICE  OF   OPHTHALMIC    MEDICINE 

AND  SURGERY.  With  one  hundred  and  seventeen  illustrations.  Third  and  revised  Ameri- 
can, with  additions  from  the  secont  London  edition.  lu  one  handsome  octavo  volume,  extra 
cloth,  of  455  pages.     $3  00. 

Seven  years  having  elapsed  since  the  appearance  of  the  last  edition  of  this  standard  work,  very 
considerable  additions  have  been  (oinid  necessiry  to  adapt  it  ihorouuhly  to  the  advance  of  ophthal- 
mic science.  The  introduction  of  the  ophthalmoscope  has  resulted  in  adding  erreatly  to  our  know- 
ledge of  the  pathology  of  the  diseases  of  the  eye,  particularly  of  its  more  deeply  seated  tissues,  and 
corresponding  improvements  in  med  cal  treatment  and  operative  procedures  have  been  introduced. 
All  these  matters  the  editor  has  endeavoured  to  add,  bearing  in  mind  the  character  of  the  volume  as  a 
condensed  anH  practical  manual  To  accommodate  this  unavoidable  increase  in  the  size  of  the  work, 
its  form  has  been  changed  tVom  a  duodecimo  to  an  octavo,  and  it  is  presented  as  worthy  a  continu- 
ance of  the  favour  which  has  been  bestowed  on  former  editions. 

A  complete  series  of  "  test-types"  for  examining  the  accommodating  power  of  the  eye,  will  be 
found  an  important  and  useful  addition. 


JONES  (C.  HANDFIELD),  F.  R.  S.,  &   EDWARD   H.  SIEVEKING,   M.D., 

Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hospital,  London. 

A  MANUAL  OF  PATHOLOGICAL   ANATOMY.    First  American  Edition, 

Revised.. j^With  three  hundred  and  ninety-seven  handsoiiie  wood  engravings.     In  one  large  and 

beautiful  octavo  volume  of  nearly  750  pages,  extra  cloth.     $3  75. 

As  a  concise  text-book,  containing,  in  accmdensefl  j  obliged  to  glean  from  a  great  number  of  monographs, 
form,  a  comp:ete  outline  of  wliat  is  known  in  tlie  ,  and  the  field  was  so  extensive  that  but  few  cultivated 
domain  of  Pathological  Anatomy,  it  is  perhaps  the  [  it  with  any  degree  of  sux;cess.  As  a  simple  work 
best  work  in  the  Knglish  language.  Its  great  merit  I  of  reference,  therefore,  it  is  of  great  value  to  the 
consists  in  its  completeness  and  brevity,  and  in  this  j  student  of  pathological  anatomy,  and  should  be  in 
respect  it  supplies  a  great  desideratum  in  our  lite-  every  physician's  library. —  Western  Lancet. 
rature.    Heretofore   the  student  of  pathology  was  | 


20 


BLANCHARD  &  LEA'S   MEDICAL 


KIKKES  (WILLIAM   SENHOUSE),    M.D., 

Demonaj^ator  (if  Morbid  Anatomy  at  !*t.  Bartholomew's  Hospital,  &c. 


A    MANUAL   OP   PHYSIOLOGY. 

improved  London  edition.     With  two  hundred 
12nio.  volume,  extra  cloth,     pp.  586.     $2  00. 

This  is  a  new  and  very  much  improved  edition  of 
Dr.  Kirkes'  well-known  Handbook  of  Physiology. 
It  combines  coneifeness  with  completeness,  and  is, 
therefore,  admirably  adapted  for  consultation  by  the 
busy  practitioner. — Dublin  Quarterly  Journal. 

One  of  the  very  best  handbooks  of  Physiology  we 
possess— presenting  just  such  an  outline  of  the  sci- 
ence as  the  student  requires  during  his  attendiinet 
npon  a  course  of  lectures,  or  for  reference  whilst 
preparing  for  examination —il»7i.  Medical  Journal 

Its  excellence  is  in  its  eompactness,  its  clearnese. 


A  new  American,  from  the   third  and 

illustrations.    In  one  large  and  hand.some  royal 


and  its  carefully  cited  authorities.  It  is  the  most 
convenient  of  text-books.  These  gentlemen,  Messrs. 
Kirkes  and  Paget,  have, the  gift  of  telling  us  what 
we  want  to  know,  without  thinking  it  necessary 
to  tell  us  all  they  know. — Boston  Med.  and  Surg. 
Journal. 

For  the  student  beginning  this  study,  and  the 
practitioner  who  has  but  leisure  to  refresh  his 
memory,  this  book  is  invaluable,  as  it  contains  all 
that  it  is  important  to  know. — Charleston  M*d. 
Journal. 


KNAPP'S  TECHNOLOGY ;  or.  Chemistry  applied 
to  the  Arts  and  to  Manufactures.  Edited  by  Dr. 
Ronalds,  Dr.  Richardson,  and  Prof.  W.  R. 
Johnson.  In  twohandsom<  8vo.  vols  .extra  cloth, 
With  about  500  wood- engravings.     36  00. 


LAYCOCK'S  LECTURES  ON  THE  PRINCI- 
PLES AND  METHODS  OF  MEDICAL  OB- 
SERVATION AND  RESEARCH.  For  the  Use 
of  Advanced  Students  and  Junior  Practitioners. 
In  one  royal  l'2mo.  volume,  extra  cloth.  Price  81. 


LALLEMAND  AND  WILSON. 
A    PRACTICAL    TREATISE    ON    THE    CAUSES,    SYMPTOMS,    AND 

TREATMENT  OF  SPERM ATORRHCEA.     By  M.  Lallemand.     Translated  and  edited  by 

Henry  J   McDougall.     Third  American  edition.     To  which  is  added ON  DISEASES 

OF  THE  VESiCUL.'E  SEMINALES;  and  their  associated  organs.  With  special  refer- 
ence to  the  Morbid  Secretion!-  of  the  Prostatic  and  Urethral  Mucous  Membrane.  By  Makkis 
Wilson,  M.  D.    In  one  neat  octavo  volume,  of  about  400  pp.,  extra  cloth.  $2  25, 


LA   ROCHE  (R.),    M.  D.,  &c. 
YELLOW  FEVER,  considered  in  its  Historical,  Pathological,  Etiological,  and 

Therapeutical  Relations.  Including  a  Sketch  of  the  Disease  as  it  has  occurred  in  Philadelphia 
from  1699  to  18-54,  with  an  examination  of  the  connections  between  it  and  the  fevers  known  under 
the  same  name  in  other  parts  of  temperate  as  well  as  in  tropical  regions.  In  two  large  and 
handsome  octavo  volumes  of  nearly  1500  pages,  extra  cloth.     $7  00. 

nant  and  unmanageable  disease  of  modern  times, 
has  for  several  years  been  prevailing  in  our  country 
to  a  greater  extent  than  ever  before;  that  it  is  no 
longer  confined  to  either  large  or  small  cities,  bat 
penetrates  country  villages,  plantations,  and  farm- 
houses; that  it  is  treated  with  scarcely  better  suc- 
cess now  than  thirty  or  forty  years  ago;  that  there 
is  vast  mischiefdone  by  ignorant  pretenders  to  know- 
ledge in  regard  to  the  disease,  and  in  view  of  the  pro- 
bability that  a  majority  of  southern  physicians  will 
be  called  upon  to  treat  the  disease,  we  trust  that  this 
able  and  comprehensive  treatise  will  he  very  gene- 
rally read  in  the  south. — Memphis  Med.  Recordsr. 


From  Professor  S.  IT.  Dickson,  Charleston,  S.  C, 
September  18,  1855. 

A  monument  of  intelligent  and  well  applied  re- 
aearch,  almost  without  example.  It  is,  indeed,  in 
itself,  a  large  library,  and  is  destined  to  constitute 
the  special  resort  as  a  book  of  reference,  in  the 
subject  of  which  it  treats,  to  all  future  time. 

We  have  not  time  at  present,  engaged  as  we  are, 
by  day  and  by  night,  in  the  work  of  cnmhating  this 
very  disease,  now  prevailing  in  our  city,  to  do  more 
than  give  this  cursory  notice  of  what  we  consider 
as  undoubtedly  the  most  able  and  erudite  medical 
publication  our  country  has  yet  produced  But  in 
view  of  the  startling  fact,  that  this,  the  most  malig- 


BY  THE  SAME  AUTHOR. 


PNEUMONIA ;  its  Supposed  Connection,  Pathological  and  Etiological,  with  Au- 
tumnal Fevers,  including  an  Inquiry  into  the  Existence  and  Morbid  Agency  of  Malaria.  In  one 
handsome  octavo  volume,  extra  cloth,  of  500  pages.    $3  00. 


LAWRENCE  (W.),   F.  R.  S.,  8cc. 
A  TREATISE    ON    DISEASES    OF    THE    EYE.     A    new  edition,  edited, 

with  numerous  additions,  and  243  illustrations,  by  Isaac  Hays.  M.  D.,  Surgeon  to  Will's  Hospi- 
In  one  very  large  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leather 


tal,  &c. 

with  raised  bands. 


$7  00. 


LUDLOW  (J.   L.),   M.  D. 


A  MANUAL   OF    EXAMINATIONS   upon   Anatomy,   Physiology^  Surgery, 

Practice  of  Medicine,  Obstetrics.  Materia  Medica,  Chemistry,  Pharmacy,  and  Therapeutics.  To 
which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised  and  greatly  extended 
and  enlarged.  With  370  illustrations.  In  one  handsome  royal  12ino.  volume,  ol  81b  large 
page.-,  extra  cloth,  $2  75. 

We  know  of  no  better  companion  for  the  student  I  crammed  into  his  head  by  the  various  professors  to 
during  the  hours  spent  in  the  lecture  room,  or  to  re-  wlunn  he  is  compelled  to  listen. —  Western  Lanttt^ 
fiesh,  at  a  glance,  his  memory  of  the  various  topics  |  May,  1857. 


AND    SCIENTIFIC    PUBLICATIONS. 


21 


LEHMANN   (C.  G.) 
PHYSIOLOGICAL    CHEMISTRY.      Translated  from  the  second   edition   by 

George  E.  Day,  M.  D.,  F.  R.  S.,  &c  ,  edited  by  R.  E.  Rogkrs,  M.  D.,  Professor  of  Chemistry 
in  the  I^edieal  Uepartment  of  the  LFniversity  of  Pennsylvania,  with  illustrations  selected  from 
Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Complete  in  two  large 
and  handsome  octavo  volumes,  extra  cloth,  containing  1200 pages,  with  nearly  two  hundred  illus- 
trations. $6  00. 
The  work  of  Lehmann  stands  unrivalled  as  the  I      The  most  important  contribution  as  yet  made  to 

most  cotnprehensive  book  of  refereufe  and  inforrna-  |  PhyEinli)-;jciij  Chemistry. — Am.  Journal  Med.  Sci- 

tion  extant  nn  fverv  branch  of  the  xuh.iect  on  which  I  tnces,  Jan.  1856. 

it  treats. — Edinburgk  J ournal  of  Medical  Science.  \ 

BY  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL   PHYSIOLOGY.      Translated  from  the  German, 

with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory  Essay  on  Vital 
Force,  by  Professor  Samtiel  Jackson,  M.  U.,  of  the  TJniversiiy  of  Pennsylvania.  With  illus- 
trations on  wood.     In  one  very  handsome  octavo  volume,  extra  cloth,  of  336  pages.    $2  25. 


LYONS  (ROBERT   D.),    K.  C.  C, 
Late  Patholoffist  in-chief  to  the  British  Army  lu  the  Crimea,  &c. 

A  TREATISE  ON"  FEVER;  or,  selections  from  a  course  of  Lectures  on  Fever. 
Being  part  of  a  course  of  Theory  and  Practice  of  Medicine.  In  one  neat  octavo  volume,  oi  362 
pages,  extra  cloth ;  $2  00.     {^Jnst  Issued.) 


This  is  an  admirable  work  upon  the  most  remark- 
able and  most  important  class  of  diseases  to  whicf 
mankind  are  liable. — Med.  Journ.  of  N.  Carolina 
May,  1661. 

We  have  great  pleasure  in   recommending  Dr. 


Lyons'  work  on  Ve.vr  to  the  attention  of  the  pro- 
fession. It  is  a  work  wliich  cannot  fail  to  enhance 
the  author's  previous  well-earned  reputation,  as  a 
diligent,  careful,  and  accurate  observer. — British 
Med.  Journal,  March  2,  1861. 


MEIGS  (CHARLES   D.),  M.  D., 

Lately  Professor  of  Obstetrics,  &.c.  in  the  Jefferson  Medical  College,  Philadelphia. 

OBSTETRICS:   THE  SCIENCE  AND  THE  ART.     Fourth  edition,  revised 

and  improved.    With  one  hundred  and  twenty-nine  illustralrons.  In  one  beautifully  printed  octavB 
volumcj  of  seven  hundred  and  thirty  large  pages,  extra  cloth,  $4  00. 

From  the  Author's  Preface. 

"  [n  this  edition  I  have  endeavored  to  amend  the  work  by  changes  in  its  form  ;  by  careful  cor- 
rections of  many  expre??ions,  and  by  a  few  omissions  and  some  additions  as  to  the  text. 

"The  Student  will  find  that  I  have  recast  the  article  on  Placenta  Praevia,  which  1  was  led  to  do 
out  of  my  desire  to  notice  certain  new  modes  of  treatment  which  I  regarded  as  not  only  ill  Ibunded 
as  to  the'philosophy  of  our  department,  but  dangerous  to  the  people. 

."  In  changing  the  form  of  my  work  by  dividing  it  into  paragraphs  or  sections,  numbered  from  1 
to  959,  1  thought  to  pre>ent  to  the  reader  a  common-place  book  (.f  the  whole  volume  Snch  a  table 
of  contents  ought  to  prove  both  convenient  and  useful  to  a  Student  while  attending  public  lectures." 

A  work  which  has  enjoyed  so  extensive  a  reputation  and  has  been  received  with  siich  general 
favor,  re(iiiires  only  the  a>surance  that  the  author  has  labored  assiduously  to  embody  in  his  new 
edition  whatever  has  been  found  necessary  to  render  it  fully  on  a  level  with  the  most  advanced 
frtate  of  the  subject.  Both  as  a  text-book  for  the  student  and  as  a  reliable  work  of  reference  for 
the  practitioner,  it  is  therefore  to  be  hoped  that  the  volume  will  be  found  worthy  a  continuance  of 
the  conlidence  reposed  iu  previous  editions. 

BY  the  same  author.    {Just  Issued.) 

WOMAN:  HER  DISEASES  AND  THEIR  REMEDIES.  A  Series  of  Lec- 
tures to  his  Class.  Fourth  and  Improved  edition.  In  one  large  and  beautifully  printed  octave 
volume,  extra  cloth,  of  over  700  pages.       $4  00. 


In  other  respects,  in  <)ur  estimation,  too  much  can- 
not he  said  in  praise  of  this  work.  It  ajounds  with 
beautiful  passages,  and  for  conciseness,  for  origin- 
ality, and  for  all  that  is  commendable  in  a  wM^>rk  on 
the  diseases  of  females,  it  is  not  excelled,  and  pro- 
bibly  not  equalled  in  the  English  language.  On  the 
whole,  we  know  of  no  worn  on  the  diseases  of  wo- 
men which  we  can  so  cordially  commend  to  the 
Bludent !.  nd  practitioner  as  the  one  before  us. — Ohio 
Med.  and  Surg.  Journal. 

The  l)ody  of,the  book  is  worthy  of  attentive  con- 
siderati(m,  and  is  evidently  the  production  of  a 
clever,  thouglitful,  and  sagacious  physician.  Dr. 
Meigs's  letters  on  the  diseases  of  llie  external  or- 
gans, contain  many  interesting  and  rare  cases,  and 
many  instructive  observations.  We  take  our  leave 
of  Dr.  Meigs,  with  a  high  opinion  of  his  talents  and 
originality. — The  British  and  Foreign  Medico-Vhi- 
Turgical  Review. 

Every  chapter  is  replete  with  practical  instruc- 
tion, and  bears  the  impress  of  being  the  coiiiposiliim 
of  an  acute  and  experienced  mind.  There  is  a  terse- 
ness, and  at  the  same  tune  an  accuracy  in  his  de- 
■criptiuaol  symptoms,  and  iu  the  rules  lor  diaguusis, 


which  cannot  fail  to  recommend  the  volume  to  the 
attention  of  the  reader. — Ranking''s  Abstxact. 

It  contains  a  vast  am(mnt  of  practical  knowledge. 
3y  one  who  has  accurately  observed  and  retained 
the  experience  of  many  years. — Dublin  Quarterly 
Journal. 

Full  of  important  matter,  conveyed  in  a  ready  and 
agreeaole  manner.— Sriowii  Med.  and  Surg.  Jour. 

There  is  an  off-hand  fervor,  aglow,  and  a  warm- 
aeartedness  infecting  the  effjrt  of  Dr,  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  reader  through  from  beginning  to  end.  Be- 
iides,  the  book  teems  with  solid  instruction,  and 
It  shows  the  very  highest  evidence  ■>f  ability,  viz., 
the  clearness  with  which  the  information  is  pre- 
sented. We  know  of  no  better  test  of  ime's  under- 
jtanding  a'  subject  than  the  evidence  of  the  power 
)f  lucidly  explaining  it.  The  most  elementary,  as 
■veil  as  the  obscurest  subjects,  under  the  pencil  of 
i'rof.  Meigs,  are  isolated  and  made  to  stand  out  in 
such  bold  reliel,  as  to  produce  distinct  impression! 
upon  the  mind  and  memory  of  the  reader.  —  Tkt 
Charleston  Med.  Journal. 


22 


BLANC-HARD    &    LEA'S    MEDICAL 


MEIGS  (CHARLES  D.).  M.  D., 
Lately  Professor  of  Obstetiics,  &c.,  in  Jefferson  Medical  College,  Philadelphia. 

ON    THPJ    NATURE,    SIGNS,    AND    TREATMENT    OF    CHILDBED 

FEVER.     In   a  Series  of  Letters  addressed  to  the  Students  of  his  Class.     In  one  hanffsome 

octavo  volume,  extra  cluth,  ol  365  pages.     $2  50.  ♦ 

The  instrnctive   and   interesting   author   of  this    lectable  book.  *     *    *   This  treatise  upon  child 


bed  fevers  will  have  an  e.xlinsive  sale,  being  des- 
tined, as  it  di-serves,  to  find  a  place  in  the  library 
of  every  practitioner  who  scorBi>  toiag  in  the  rear. — 
Nashville  Journal  of  MedirAne  and  Surgery. 


work,  whiise  previous  lab.irs  have  placed  his  e 
trynien  under  deep  and  abiding  obligations,  again 
challenges   their  admiration  in  the  fresh  and  vigor 
CUB,  attractive  and  racy  pages  before  us.    It  is  a  de- 

BY   THE   SAME    AITTHOR  ;    WITH  COLORED  PLATES. 

A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK 

OF  THE  UTERUS.     With  numerous  plates,  drawn  and  colored  from  nature  in  the  highest 
«tyle  of  art.    lu  one  handsome  octavo  volume,  extra  cloth.     $5  f  0 


MACLISE   (JOSEPH),    SURGEON. 
SURGrlCAL   ANATOMY.     Forming   one  volume,   very  large  imperial  quarto. 

With  sixty-eight  large  and  splendid  Plates,  drawn  in  the  Lest  style  and  beautifully  colored.  Con- 
taining one  hundred  and  ninety  Figure.^,  many  oi  them  the  size  oJ  life.  Together  with  copious 
and  explanatory  letter-press.  Strongly  and  handsomely  bound  in  extra  cioih,  being  one  of  the 
cheapest  and  best  executed  Surgical  works  as  yet  issued  in  this  country.    $12  00. 

Geutlemeii  preparing  for  service  in  the  field  or  hospital  will  find  these  plates 
of  the  highest  practical  value,  either  for  consultation  in  emergencies  or  to  refresh 
their  recollection  of  the  dissecting  room. 

*^*  The  size  of  thi.«  work  prevents  its  transmission  through  the  post-office  as  a  whole,  but  those 
who  desire  to  have  copies  forwarded  by  mail,  can  receive  them  in  five  parts,  done  up  in  stout 
wrappers.     Price  S9  00. 

A  work  which  has  no  parallel  in  point  of  accu- 
racy and  cheapness  in  the  English  language. — N.  Y. 
Journal  of  Medicine. 

We  are  extremely  gratified  to  announce  to  th« 
profession  the  completion  of  this  truly  magnificent 
work,  which,  as  a  whole,  certainly  stands  unri- 
valled, both  for  accuracy  of  drawing,  beauty  of 
coloring,  and  all  the  requisite  explanations  of  tha 
subject"  in  hand. — Thi  Nev  Orleans  Medical  ani 
Surgical  Journal. 


One  of  the  greatest  artistic  triumphs  of  the  age 
in  Surgical  Anatomy. — British  American  Medical 
Journal. 

No  practitioner  whose  means  will  admit  should 
fall  to  possess  it. — Ranking's  Abstract. 

Too  much  cannot  be  said  m  its  praise;  indeed, 
we  have  not  language  to  do  it  justice.— OAio  Medi- 
cal and  Surgical  Journal. 

The  most  accurately  engraved  and  beautifully 
colored  plates  we  have  ever  seen  in  an  American 
book — one  of  the  best  and  cheapest  surgical  works 
ever  published. — Buffalo  Medical  Journal 

It  is  very  rare  that  so  elegantly  printed,  so  well  1 
illustrated,  and  so  useful   a  work,  is   I'flered  at  so 
moderate  a  price. — Charleston  Medical  Journal. 


This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy  that  has  come   under  our  observation.    W* 
know  of  no  other  work  that  would  justify   a  stu- 
dent, in   any  degree,  for  nesleet  of  actual  dissec- 
I  t'ion.     In   those  sudden   emergencies  that   so  often 
I  arise,  and  which  require  the instantaneouscommand 
Its   plates  can  boast  a  superiority  which  places  ;  „f„„nufe., „at,„^,pal  ljn,,wledge,  «  work  of  this  kjnd 
themalraost  beyond  thereachof  competition.— Msrfi-  ;  i^^eps  ttie  details  of  the  dissecting-room  perpetually 
tal  Examiner.  j  frygi,  j„  tj,e  memory.— TA*  WtsUm  Journal  of  Mcdi- 

Country  practitioners  will  find  these  plates  of  im-     cine  and  Surgery. 
mense  value. — JV.  y.  Medical  Gazette.  ' 


MILLER  (HENRY),  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c. ;  including  the  Treat- 

ment  of  Chronic  Inllammation  of  the  Cervix  and  Body  of  the  Uterus  considered  as  a  frequent 
cause  of  Abortion.  With  about  one  hundred  illustration*  on  wood.  In  one  very  handsome  oc- 
tavo volume,  of  over  600  pages,  extra  cloth.     $-3  75. 

tion  to  which  its  merits  justly  entitle  it. — The  Cin- 
cinnati Lancet  and  Observer. 


We  congratulate  the  author  that  the  task  is  done. 
We  congratulate  him  that  he  hasgiven  to  the  medi- 
cal public  a  work  which  will  secure  for  him  a  high 
and  permanent  position  among  the  standard  autho- 
rities on  the  principles  and  practice  of  obstetrics. 
Congratulations  are  not  less  due  to  the  medical  pro- 
fession of  this  country,  on  the  acquisition  of  a  trea- 
tise embodying  the  results  of  the  studies,  reflections, 
and  experience  of  Prof.  Miller.— £u^a/o  Medical 
Journal. 

In  fact,  this  volume  must  take  its  place  among  the 
standard  systematic  treatises  on  obstetrics  ;  a  posi- 


A  most  respectable  and  valuable  addition  to  our 
home  medical  literature,  and  one  rcliecling  credit 
alike  on  the  author  and  the  institution  to  wnich  he 
is  attached.  The  student  will  find  in  this  work  a 
most  useful  guide  to  his  studies;  the  country  prac- 
tirione'r,  rusty  in  his  reading,  can  obtain  from  its 
pages  a  fair  resume  of  the  modern  literature  of  the 
science;  and  we  hope  to  see  this  American  produc- 
tion generally  consulted  by  the  profession. —  F«. 
Med.  Journal. 


MACKENZIE    (W.),    M.D./ 

Surgeon  Oculist  in  Scotland  in  ordinary  to  Her  Majesty,  A.C.&.C. 

A  PRACTICAL   TREATISE  ON    DISEASES    AND  INJURIES  OF   THE 

EYE.  To  which  is  prefixed  an  Aiiatotiiical  Introduction  explanatory  of  a  Horizontal  Section  ol 
the  Human  Eyeball,  by  Thomas  Wharton  Jones,  F.  R.  3.  From  the  Fourth  Revised  and  En- 
larged London  Edition.  With  Notes  and  Additions  by  Addinell  Hewson,  M.  D.,  Surgeon  to 
wills  Ho>pital.  itec.  izc.  In  one  very-large  and  handsome  octavo  volume,  extra  cloth,  with  plates 
and  numerous  wood-cuts.     $5  50. 


The  treatise  of  Dr   Mackenzie  indisputably  holds 
the  first  place,  and  forms,  in  respect  of  learning  and 
research,  an  Kncycloprrdia  unequalled  in  extent  by 
any  rithcr  work  of  the  kinil,eith':r  English  or  foreign.  1 
—Dixon  on  Diseases  of  the  Eyt.  \ 


We  consider  it  the  duty  of  every  one  who  has  the 
love  of  his  professior  and  the  welfare  of  his  patient 
at  heart,  to  make  himself  familiar  with  this  the  most 
complete  work  in  the  English  language  up(m  thcdis- 
eases  of  the  eye. — Med.  Tinus  and  Gazett*. 


AND    SCIENTIFIC    PUBLICATIONS 


23 


MILLER  (JAMES),   F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Edinburgh,  See. 

PRTNCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and  revised 

Edinburgh  edition.    In  one  large  and  very  beautiful  volume,  extra  cloth,  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood.     $3  75. 

BY   THE  SAME   AUTHOR. 

THE   PRACTICE   OF   SURGERY.      Fourth   American  from  the  last  Edin- 

burgh  edition.     Revised  by  the  American  editor.    Illustrated  by  three  himdred  and  sixtv-four 
engravings  on  wood.     In  one  large  octavo  volume,  extra  cloth,  of  nearly  700  pages.     $3  7-5. 
No  encomium  of  ours  could  add  to  the  popularity  |  his  works,  both  on  the  principles  and  practice  ol 


of  Miller's  Surojery.  Its  reputation  in  this  country 
is  unsurpassed  by  that  of  any  other  work,  iind,  when 
taken  in  connection  with  the  autlior'g  Prinriples  of 
Surgery,  constitutes  a  whole,  without  reference  to 
which  noeonscientious  surgeon  would  he  willing  to 
practice  his  art. —  Southern  Med .  and  Surg .  Journal. 
It  is  seldom  that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
"  Principles"  and  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merite<l  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  well-informed  man,  who  knows 
exactly  what  he  is  talking  about  and  exactly  how  to 
talk  it. — Kentucky  Medical  Recorder. 

By.  the  almget  unanimous  voice  of  the  profession, 


surgery  have  been  assigned  the  highest  rank.  If  we 
were  limited  to  but  one  work  on  surgery,  that  one 
should  be  Miller's,  as  we  regard  it  as  superior  to  all 
others. — St.  Louis  Med.  and  Surg.  Journal. 

The  author  has  in  this  and  his  "  Principles,"  pre- 
sented to  the  profession  one  of  the  most  complete  and 
reliable  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, concise,  and  lucid.  Few  have  the  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  theattention.  Whether 
as  a  text-book  for  stuilents  or  a  book  of  reference 
for  practitioners,  it  cannot»be  too  strongly  recom- 
mended.— Southern  Journal  of  Med.  and  Physical 
Sciences. 


MORLAND  (W.  W.),   M.  D., 

Fellow  of  the  Massachusetts  Medical  Society,  &c. 


DISEASES  OF  THE  URINARY  ORG 

Pathology,  and  Treatment.     With  illustrations 

about  600  pages,  extra  cloth.     $3  50. 

Taken  as  a  whole,  we  can  recommend  Dr.  Mor- 
land's  compendium  as  a  very  desirable  addition  to 
the  library  iif  every  medical  or  surgical  practi- 
tioner.— Brit  and  For.  Med.-Chir.  Rev.,  April,  1859. 

Every  medical  practitioner  whose  attention  has 
been  to  any  extent  attracted  towards  tiie  class  of 
diseases  to  which  this  treatise  relates,  must  have 
often  and  sorely  experienced  the  want  of  some  full, 
yet  concise  recent  compendium  to  which  he  could 


ANS  ;  a  Compendium  of  their  Diagnosis, 
In  one  large  and  handsome  octavo  volume,  of 

refer.  This  desideratum  has  been  supplied  by  Dr. 
Morland,  and  ii  has  been  ably  done.  He  has  placed 
before  us  a  full,  judicious,  and  reliable  digest. 
Each  subject  is  treateil  with  sufficient  minuteness, 
yet  in  a  succinct,  narrational  style,  such  as  to  render 
the  worK  one  of  great  interest,  and  one  which  will 
prove  in  tlie  highest  degree  useful  to  the  general 
practitioner. — N.  Y.  Journ.  of  Medicine y 


BY  THE  SA-ME  AUTHOR. 


THE  MORBID  EFFECTS  OF  THE   RETENTION  IN  TIIE   BLOOD  OP 

THE  ELEMENTS  OF  THE  URINARY  SECRETION.  Being  the  Dissertation  to  which  the 
Fiske  Fund  Prize  was  awarded,  July  11,  1S61.  In  one  small  octavo  volume,  83  pages,  extra 
cloth.     75  cents. 


MONTGOMERY  (W.  F.),    M.  D.,   M.  R.  I.  A.,  8e.c., 

Professor  nf  Midwifery  in  the  King  and  Queen's  College  of  Physicians  iu  Ireland,  &c. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

With  some  other  Papers  on  Subjects  connected  with  Midwifery.     From  the  second  and  enlarged 
English  edition.     With  two  exquisite  colored   plates,  and  niiinerous  wood-cuts.     In  one  very 
handsome  octavo  volume,  extra  cloth,  of  nearly  600  pages.     $3  75. 
A  book  unusually  rich  in  practical  suggestions.—  i  fresh,  and  vigorous,  and  classical  is  our  author's 


Am   Journal  Med.  Sciences,  Jan.  1857, 

These  several  subjects  so  interesting  in  them- 
selves, and  so  important,  every  one  of  them,  to  the 
most  delicate  and  precious  of  social  relations,  con- 
trolling often  the  honor  and  domestic  peace  of  a 
family,  the  legitimacy  of  offspring,  or  the  life  of  its 
parent,  are  all  treated  with  an  elegance  of  diction, 
fulness  of  illustrations,  acutenessand  justice  of  rea- 
soning, unparalleled  in  obstetrics,  and  unsurpassed  in 
medicine.    The  reader's  interest  can  never  flag,  so 


style;  and  one  forgets,  in  the  renewed  charm  of 
»verv  page,  that  it,  and  every  line,  and  every  word 
has  been  weighed  and  reweiglied  through  years  of 
preparation;  that  this  is  of  "all  others  the  book  of 
Obstetric  Law,  on  each  of  its  several  topics;  on  all 
points  connected  with  pregnancy,  to  be  everywhere 
received  aJ  a  manual  of  special  jurisprudence^  at 
once  announcing  fact,  affonlingargument,  establish- 
ing precedent,  a'nd  governing  alike  the  juryman,  ad- 
vocate, and  judge.  — N.  A.  Med.-Chir.  Review. 


MOHR  (FRANCIS),  PH.  D.,  AND  REDWOOD  (THEOPHILUS). 
PRACTICAL    PHARMACY.     Comprising  the  Arrangements,  Apparatus,  and 

Manipulations  of  the  Pharmaceutical  Shop  and  Laboratory.  Edited,  with  extensive  Additions, 
by  Prof  William  Procter,  ol  the  Philadelphia  College  of  Pharmacy.  In  one  handsomely 
printed  octavo  volume,  extra  cloth,  of  570  pages,  with  over  500  engravings  on  wood.     $3  50. 


MAYNE'S  DISPF.NS.\TORY  AND  THERA- 
PEUTICAL RKMKMHR.ANCER.  \\ith  every 
Practical  Formula  contained  in  the  three  British 
Pharmacopoeias  Edited,  with  the  addition  of  the 
Formufe  of  the  U.  f?  Pharmaeopreia,  by  R.  E. 
SeiffitHj.M.D    1  12mo.  vol.ex.cl.jSOOpp.  75  c. 


MALGAIGNE'S  OPERATIVE  SURGERY,  based 
on  Normal  and  Pathological  Anatomy.  Trans- 
lated from  the  French  by  Frederick  Brittan, 
A.  B.,M.  D.  Withnamerous  illustrations  on  wood. 
In  one  handsome  octavo  volume,  extra  cloth,  of 
nearly  six  hundred  pages.    $2  50. 


21 


BLANCHARD   &   LEA'S    MEDICAL 


NEILL  (JOHN),   M,  D., 

Siirg:eoTi  to  the  Pennsylvania  Hfigpital,tc.;  and 

FRANCIS  GURNEY    SMITH,   M.  D., 
Professor  of  Institutes  of  Medicine  in  the  Pennsylvania  Medical  College. 

AN  ANALYTTHAL   COMPENDIUM    OF   THE    VARIOUS    BEANCHES 

OF  MEDICAL  SCIENCE;  for  ihe  Use  and  Examination  of  Studenti*.  A  new  edition,  revised 
and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo.  volume,  of  about  one 
thousand  paees,  with  374  wood-cut?,  extra  cloth,  $3  50.  Strongly  bound  in  leather,  with  raised 
bands.     S4  00 

This  work  is  again  pre'»ented  as  eminently  worthy  of  the  favor  with  which  it  has  hitherto 
been  received.  As  a  book  for  daily  reference  liy  the  student  requirin^a  guide  to  his  more  elaborate 
text-books,  as  a  manual  for  precepiors  desiring  to  stii.inlate  their  students  by  frequent  and  accurate 
examination,  or  as  a  source  from  which  the  practitioners  of  older  date  may  easily  and  cheaply  acquire 
a  knowledge  of  the  changes  and  improvement  in  professional  science,  its  reputation  is  permanently 
e«tabli>hed. 


The  beat  wori  of  the  kind  with  which  we  are 
acquainted. — Med.  Examiner. 

Having  nnade  free  use  of  this  volume  In  our  ex- 
aminatidns  of  pupils,  we  can  speak  from  experi- 
ence in  recommending  it  as  an  admirable  conipend 
for  students,  and  as  especially  useful  to  preceptorf 
v/h<>  examine  their  pupils.  It  will  save  the  teacher 
much  labor  by  enabling  him  readily  to  recall  all  of 
the  points  upon  whicti  his  pupils  should  be  ex- 
amined. A  work  of  this  sort  ahnuld  be  in  the  iiandf 
of  every  one  who  takes  pupiU  into  his  office  with  a 
view  of  examining  them  ;  and  this  isunq\iesfionably 
the  best  of  its  class. — Transylvania  Med.  Journal 

In  the  rapid  course  of  lectures,  where  work  for 


the  students  is  heavy,  and  review  necessary  for  an 
examinafi(m,  a  compend  is  not  only  valuable,  but 
it  is  almost  a  sine  qua  non.  The  one  before  us  is, 
in  most  of^  the  divisions,  the  most  unexceptionable 
of  all  hooks  of  the  kind  that  we  know  of.  Tha 
newest  and  soundest  doctrines  and  the  latest  ira- 
proveracntE  and  discoveries  are  explicitly,  though 
eonciseiy,  laid  before  the  student.  There  is  a  class 
to  whom  we  very  sincerely  commend  this  cheap  book 
as  worth  its  weight  in  silver — that  class  is  the  gradu- 
ates in  medicine  of  more  than  ten  years'  standing, 
who  have  not  studied  medicine  since.  They  will 
perhaps  Snd  out  from  it  that  the  science  is  not  exactly 
now  what  it  was  when  they  left  it  off. — Tii*  Stake- 
scope 


NELIGAN  (J.    MOORE),  M.  D.,  M.  R.  I. A.,  &c. 
ATLAS  OF  CUTANEOUS  DISEASES.     In  one  beautiful  quarto  volume,  extra 

cloth,  with  splendid  colored  plates,  presenting  nearly  one  hundred  elaborate  representations  of 
di-sease.     $4  75. 

This  beautiful  vohime  is  intended  as  a  complete  and  accurate  repi'e.«entation  of  all  the  varieties 
of  Diseases  of  the  Skin.  While  it  can  he  consulted  in  conjunction  with  any  work  on  Practice,  it  has 
especial  reference  to  the  author's  "  Treatise  on  Diseases  ot  the  Skin,"  so  favorably  received  by  the 
profession  some  years  since.  The  publishers  feel  justified  in  saying  that  few  more  beautifully  exe- 
cuted p'ates  have  ever  iieen  presented  to  the  profession  of  this  country. 

eive,  at  a  covp  d'ail,  the  remarkable  peculiarities 
of  each  individual  variety.  And  while  thus  the  dis- 
ease is  rendered  more  deSnalile.  there  is  yet  no  loss 


Nehean's  Atlas  of  Cutaneous  Diseases  supplies  a 
long  existent  desideratum  much  f^lt  Dy  the  largesi 
class  of  our  prol'ession.  U  presents,  in  quarto  size, 
16  plates,  each  containing  from  -3  to  6  figures,  and 
forming  in  all  a  total  f>f  90  i1istin''t  represent;itions 
of  the  different  sjiecies  of  skin  affections,  grouped 


if  oroportion  incurred  by  the  necessary  concentra- 
tion. F^aeh  figure  is  highly  colored,  and  so  truthful 
has  :he  artist  been  that'the  mostfastid  ous  observer 


together  in  genera  or   families.     The  illustrations  |  could  not  justly  take  exception  to  the  eorreetn'-sa  of 
have  been  taken  from  nature,  and   have  teen  copied  I  the  execution  of  the  pictures  under  his  scrutiny. — 
With  such  fidelity  that  they  present  a  striking  picture     Montreal  Med.  CkronicU. 
of  life;  in  Which  the  reduced  scale  aptly  serves  to  I 

BY  THE  SAME  AUTHOR. 

A    PRACTICAL   TREATISE    ON    DISEASES  OF  THE  SKIN.     Fourth 

American  edition.     In  one  neat  royal  12mo.  volume,  extra  cloth,  of  334  pages.     $1  25. 


OWEN    ON    THE    DIFFERENT    FORMS    OF 
THE   SKELETON,   AND    OF   THE   TEETH. 


One  vol.  royal  12mo.,  extra  cloth  with  numeroui 
illustrations.    31  25 


PIRRli(WILLIAM),  F.  R.  S.  e., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE    PRINCIPLES   AND   l^RACTICE  OF  SURGERY.    Edited  by  John 

Neill,  M.  D.,  Professor  ofSurgerj'  in  the  Penna.  Medical  College,  Surgeon  tothe  Pennsylvania 
Hospital,  &c.  In  one  very  handsome  8vo.  volume,  extra  cloth,  of  780  pages,  with  316  illustrations. 
S3  75. 


We  know  of  no  other  surgical  work  of  a  reason- 
able size,  wherein  there  is  so  much  theory  and  prac- 
tice, or  where  subjects  are  more  soundly  or  clearly 
taught. — The  Ste-tkoscope. 

Prof.  Pirrie,  in  the  work  before  us,  has  elabo- 


rately discussed  the  principles  of  surgery,  and  a 
safe  and  effectual  practice  predicated  upon  them. 
Perhaps  no  work  upon  this  subject  heretofore  issued 
is  so  full  upon  the  science  of  the  art  of  surgery.— 
Nashville  Journal  of  Me.dicine  and  Surgery. 


PARKER   CLANGSTON), 

Surge(m  to  the  Queen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OF  SYPHILITIC  DISEASES,  BOTH  PRI- 

MAIiy  AND  SECONDARY;  comprising  the  Treatment  of  Constitutional  and  Confirmed  Syphi- 
lis, by  a  safe  and  -successful  method.  With  numerous  Cases,  Formulas,  and  Clinical  Observa- 
tions. From  the  Third  and  entirely  rewritten  London  edition.  In  one  neat  octavo  volume^ 
extra  cloth,  of  31 6  pages.     £2  CO. 


AND   SCIENTIFIC    PUBLICATIONS. 


25 


PARRISH    (EDWARD). 

Professor  of  Materia  Medioa  iu  the  Philailelpliia  College  of  Pharmacy. 

A  TREATISE  UN  PIIARMAC^T.     Designed  as  a  Text-book  for  the  Student, 

and  us  a  Guide  for  the  Phy.sician  and  Pharmaoetitisi.    With  many  Formulae  and  Prescriptions. 

Third  edition,  g-really  improved.     In  one  handsome  octavo  volume,  of  850  pages,  with  several 

hundred  Illustrations,  extra  cloth.     $5  00.     (Just  Ready.) 

Though  for  some  time  out  of  print,  the  appearance  of  a  new  edition  of  this  work  has  been  de- 
layed lor  the  purpose  of  embodying  in  it  the  results  of  the  new  U.  S.  Pharmacopojia.  The  i)ub- 
licalion  of  this  latter  has  enabled  the  author  to  complete  his  revision  m  the  must  thorough  mat.iier. 
Those  who  have  been  waiting  for  the  work  may  therefore  rely  on  obtaining  a  volume  "comp.etely 
on  a  level  with  the  most  advanced  condition  of  paarmaceutical  science 

The  favor  with  which  the  work  has  thus  far  been  received  shows  that  the  author  was  not  mis- 
taken in  his  estimate  of  the  want  of  a  treatise  which  should  serve  as  a  practical  text-book  for  all 
engaged  in  preparing  and  dispensing  medicines.  Such  a  guide  was  indispensable  not  onlv  to  Ihe 
educated  pharmaceutist,  but  also  to  that  large  class  of  praeiitioners  throughout  the  country  wiio 
are  obliged  to  compound  their  own  prescriptions,  and  who  during  their  collegiate  course  have  no 
opportunity  of  obtaining  a  pmctical  familiarity  wiih  the  neces>ary  processes  and  manipulations. 
The  rapid  exhaui-tion  of'  two  large  editions  is  evidence  that  the  author  has  succeeded  in  thoroughly 
carrying  out  his  object.  Since  the  appearance  of  the  last  edition,  much  fas  been  done  to  perlect 
tlic  science;  the  new  Pharmacopccia  has  introduced  many  changes  to  which  the  profession  must 
conform  ;  and  the  author  has  labored  assiduously  to  embody  in  his  work  all  that  physicians  and 
pluiimaceutists  can  ask  for  in  such  a  volume.  The  new  matter  alone  will  thus  be  found  worth 
more  than  the  very  moderate  cost  of  the  work  to  those  who  have  been  using  the  previous  euitions. 


All  that  we  can  say  of  it  is  that  to  the  practising 
physician,  and  especially  the  country  physician, 
who  is  generally  his  own  apothecary,  there  is  hard- 
ly any  booic  that  mioflit  not  better  be  dispensed  witii. 
It  IS  at  the  snme  time  a  dispensatory  and  a  pharma- 
cy.— Louisville  Revieio. 

A  careful  examination  of  this  work  enables  vis  to 
speak  of  it  in  the  highest  terms,  as  being  tiie  best 
treatise  on  practical  pharmacy  with  winch  we  are 
acquainted,  and  an  invaluable  vide-w.ec.um,  not  only 
to  the  apothecary  and  to  those  practitioners  who 
are  accustomed  to  prepare  tl  eir  own  medicines,  but 
t">  every  medical  man  and  medical  student. — Boston 
Med.  and  Surg.  Journal. 

This  is  altogether  one  of  the  most  useful  books 
we  have  seen.  It  is  just  what  we  have  long  felt  to 
be  needed  by  apothecaries,  students,  and  practition- 
ers of  medicine,  most  of  whom  in  this  country  have 
to  put  up  their  own  prescriptions.  It  bears,  upon 
every  page,  the  impress  of  practical  knowledge, 
conveyed  in  a  plain  common  sense  manner,  and 
auapteJ  to  the  comprehensi  jn  of  all  wlio  may  read 
it — Southern  Med.  and  Surg.  Journal. 

That  Edward  Parrish,  in  writing  a  book  upon 
practical  Pharmacy  some  few  years  ago — one  emi- 
nently original  and  unique — did  the  medical  and 
pharmaceutical  professitms  a  great  and  valuable  ser- 
vice, no  one,  we  think,  wlio  has  had  access  to  its 
pages  will  deny;  doubly  welcome,  then,  is  this  new 


edition,  containing  the  added  results  of  his  recent 
and  rich  experience  as  an  observer,  teaGft«T,  and 
practic  tl  operator  in  the  pharmaceutical  laboratory. 
The  excellent  plan  of  the  first  is  more  thoroughly, 
— Pent7isular  Med.  Journal,  Jan.  ISt/l). 

Of  course,  all  apothccuriea  who  liave  not  already 
a  copy  of  the  first  edition  will  procure  one  of  this; 
it  is,  therefore,  to  physicians  residing  in  tlie  country 
and  iu  small  towns,  who  cannot  avail  themselves  of 
the  skill  of  an  eUucated  pharmaceutist,  that  we 
would  espfcially  commend  this  work.  In  it  they 
will  find  all  that  they  desire  to  know,  and  should 
know,  but  very  little  of  wliich  they  do  really  auow 
in  reference  to  this  important  collateral  branch  o£ 
their  profession;  for  it  is  a  well  established  fact, 
ihat,  in  tbe  ecucationoi  physicians,  while  the  sci- 
ence of  medicine  is  generally  well  taught,  very 
little  attention  is  paid  to  the  art  of  preparing  tliein 
fur  use,  and  we  know  not  how  ttiis  defect  can  be  so 
well  remedied  as  by  procuring  and  Consulting  Dr. 
Parrish's  excellent  work. — St.  Louis  Med.  Journal. 
Jan.  Io60. 

We  know  of  no  work  on  the  subject  which  would 
be  more  indispensable  to  the  physician  or  student 
desiring  information  on  the  subject  of  which  it  treats. 
With  Grilfith's  "  Medical  Formulary"  and  this,  the 
practising  physician  would  be  supplied  witli  nearly 
or  quite  all  the  most  useful  infor  nation  on  the  sub- 
ject.— Charleston  Med.  Jour. and  lieview,  Jan.  ±b6i}. 


PEASLEE  (E.  R.),   M.  D., 

Professor  of  Physiology  and  General  Pathology  in  the  New  Vork  Medical  College. 

HUMAN  HISTOLOG-Y,  in  its  relations  to  Anatomy,  Physiology,  and  Fatholoey 

for  the  use  of  Medical  Students.     With  four  hundred  and  thirty-lour  illustrations.    In  one  liaiid- 
some  octavo  volume,  extra  cloth,  of  over  600  pages.     $3  75. 

It  embraces  a  library  upon  the  topics  discussed  |  We  would  recommend  it  aa  containing  a  summary 
within  Itself,  and  is  just  what  the  teacher  and  learner  of  all  that  is  known  of  tue  importai^t  subjects  which 
need.  We  iiave  not  only  the  whole  subject  of  His-  '  it  treats  ;  of  all  that  is  in  the  great  worts  of  Simon 
tology,  interesting  in  itself, ably  and  fully  discussed,  I  and  Lehmann,  and  the  organic  chemists  m  general, 
but  what  is  ol  inhnitely  greater  interest  to  the  stu-  Master  this  one  volume,  and  you  know  all  that  is 
cent,  because  of  greater  practical  value,  are  its  re-  known  of  the  great  fundamental  principles  of  medi- 
tations to  Anatomy,   Physiology,   and    Pathology,    cine,  and   we  nave  lo  hesitation  ia  saying  that  it 

which  are  here  fully  and  satisfactorily  set  forth. —     is  an  honor  to  the  American  medical  profession. 

h'ashvilleJourn.  of  Med.  and  Surgery.  I  St. Loui^Mtd.andSurg.  Journal. 


ROKITANSKY 

Curator  of  the  Imperial  Pathological  Museum, 

A    MANUAL   OF  PATHOLOGICAL 

bound  in  two,  extra  cloth,  of  about  1200  pages. 

itiNG,  C.  H.  iVIoORE,  and  G.  E.  Day.     |)d  00. 

The  profession  is  too  well  acquainted  with  the  re- 
putation of  Rokilausky's  work  to  need  our  assur- 
ance that  this  is  one  of  tlie  mostprofound,  thorough, 
and  valuable  books  ever  issued  from  the  medical 
press.  It  is  sui  ge/ieris,  and  has  no  standard  uf  com- 
parison. It  is  only  necessary  to  announce  that  it  is 
isKUed  in  a  form  as  cheap  as  is  compatible  with  its 
size  and  preservation,  and  its  sale  follows  as  a 
matter  of  ccmrse.  No  library  can  be  called  com- 
plete witlioutit. — Buffalo  Med.  Journal. 

An  attempt  to  give  our  readers  any  adequate  idea 
of  the  vast  amount  of  instruction  accumulated  in 


(CARL),    M.  D., 

and  Professor  at  the  University  of  Vienna,  &c. 

ANATOMY.     Four  volumes,   octavo, 
Translated  by  W.  E.  Swaine,  Edward  Sieve- 

these  volumes,  would  be  feeble  and  hopeless.  The 
eiforl  of  the  distinguished  author  to  concentrate 
in  a  small  space  his  great  fund  of  knowledge,  nag 
BO  cliaigcd  nis  text  witn  valuable  tiutiis,  uiai  any 
attempt  of  a  reviewer  to  epitomize  is  at  once  para- 
lyzed, and  must  end  in  a.  (d.iiate.—  Westefn  Lancet. 
As  this  18  the  nigiiest  source  of  Knowledge  upon 
the  important  subject  of  wnich  it  treats,  no  real 
student  can  alford  to  be  without  it.  The  American 
publishers  have  entitled  themselves  to  the  thanks  of 
the  profession  o[  their  country,  for  this  tinieous  and  • 
beautiful  edition.— iVaiAoiiie  Journal  of  Medieint 


26 


BLANCHARD    &    LEA'S    MEDICAL 


RIGBY    (EDWARD),   M.D., 

Senior  PhyBiciaii  to  the  General  Lying-in  Hospital,  &c. 

A    SYSTEM    OF    MIDWIFERY.     With  Notes  and   Additional  IllustrationB. 

Second  American  Edition.    One  volume  octavo,  extra  cloth,  422  puges.     $2  50. 

BY  THE  SAME  AUTHOR. 

ON  THE  CONSTITUTIONAL  TREATMENT  OF  FEMALE  DISEASES. 

In  one  neat  royal  12mo.  volume,  extra  cloth,  of  about  250  pages.    $1  00. 


RAMSBOTHAM  (FRANCIS   H.),   M.D. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND 

SURGEK  Y,  in  reference  to  the  Process'  o(  Parturition.  A  new  and  enlarged  edition,  thoroughly 
revij^ed  by  the  Author.  With  Additions  by  W.  V.  Keating,  M.  D.,  Professor  ol  Obstetrics',  &c.,  in 
the  Jetlerson  Medical  College,  Philadelphia.  In  one  large  and  handsomt  imperial  octavo  volume, 
ol  650  pages,  strongly  bound  in  leather,  with  raised  bands;  with  sixty- four  beautiful  Plales,  and 
numerous  Wood-cuts  in  the  text,  containing  in  all  nearly  200  large  and  beautiful  figures.   $6  50. 

From  Prof.  Hodge.,  of  tkt  University  of  Pa.  ■> 

To  the  American  public,  it  is  most  valuable,  from  its  intrinsic  undoubted  excellence,  and  as  being 
the  best  authorized  exponent  of  British  Midwifery.  Its  circulation  will,  I  trust,  be  extensive  throughout 
our  country. 


It  is  unnecessary  to  say  anything  in  regard  to  the 
Utility  of  this  work.  It  is  already  appreciated  in  our 
country  for  the  value  of  the  iiiaiter,  the  clearness  of 
its  styje,  and  the  fulness  of  its  illustrations.  To  the 
physician's  library  it  is  indispensable,  while  to  the 
student  as  a  text-book,  from  which  to  extract  tlie 
material  for  laying  the  foundation  of  an  education  on 
obstetrical  science,  it  lias  no  superior. — Ohio  Med 
and  Surg.  Journal. 

The  publishers  have  secured  its  success  by  the 


truly  elegant  style  in  which  they  have  brought  it 
out,  excelling  themselves  in  its  production,  espe- 
cially  in  its  plates.  It  is  dedicated  to  Prof.  Meigs, 
and  has  tlie  emphatic  endorsement  of  Prof.  Hodge, 
as  the  best  exponent  of  British  Midwifery.  We 
kn(.w  of  no  text-book  which  deserves  m  all  respect* 
to  be  more  highly  recommended  to  students,  and  we 
could  wish  to  see  it  in  the  handsofevery  practitioner, 
for  they  will  find  it  invaluable  for  reference.— itfsd. 
Gazette. 


RICORD  (P.),   M.  D. 
A  TREATISE  ON  THE  VENEREAL  DISEASB.     By  John  Hunter,  F.R.S. 

With  copious  Additions,  by  Ph  Kicord,  M.D.    Translated  and  Edited,  with  Notes,  by  FreemaS 
J.  BuMSTKAD  iVl.D.,  Lecturer  on  Venereal  at  the  College  of  Physician?  and  Su-igeons,  New  York. 
Second  editicn,  revised,  containing  a  resume  of  Ricord's  Recent  Lectures  on  Chancre.    In 
one  handsome  octavo  volume,  extra  cloth,  of  550  pages,  with  eight  plates,    $3  50. 
Every  one  will  recognize  the  attractiveness  and 
▼alue  which  this  work  derives  from  Ihus  preseniiug 
the  opinions  of  lliese  two  masters  side  by  side.    But, 
it  must  l)e  admiued,  whai  lias  made  the  fortune  of 
the  book,  is  ihe  fact  that  ii  contains  me  ■•  most  com- 
plete emiiodimeiil  of  the  veritable  doctrines  of  the 


Hopital  du  Midi,"  which  has  ever  been  made  pub- 


lic. In  conclu.iion  we  can  say  thai  this  is  incon' 
teslablythe  best  treatise  on  syphilis  with  which  wo 
are  acquainted  and,  as  we  do  iiol  often  employ  the 
phrase,  we  may  l>e  excused  for  expressing  the  hope 
thai  It  may  find  a  place  in  the  librarv  of  every  phy- 
sician.—  Virginia  Med.  and  Surg.  Journal. 


BY   THE  SAME   AUTHOR. 


RICORD'S  LETTERS  ON  SYPHILIS.   Translated  by  W.  P.  Lattimore,  M.  D- 

In  one  neat  octavo  volume,  of  270  pages,  extra  clolh.     $2  00. 


ROYLE'S   MATERIA    MEDICA   AND   THERAPEUTICS;   including  the 

Preparations  of'the  Pharmacopueias  of  London,  Edinburgh,  Dublin,  and  of  the  United  States. 
With  many  <iew  medicines.  Edited  by  Joseph  CIarson,  M.  D.  With  ninety-eight  illusirationi. 
In  one  large  octavo  volume,  extra  cloth,  of  about  700  pages.    $3  00. 


SMITH    (HENRY   H.),  M.  D.,  AND    HORNER  (WILLIAM  E.),  M.  D. 
AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the  Human  Body 
In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred  and  lifty  beautifiil 
figures.     i4  00. 


The  plan  of  this  Atlas,  which  renders  it  so  pe- 
culiarly convenient  for  the  student,  and  its  superb 
nrtistical  execution,  'lave  been  already  pointed  out 
We  must  congratulate  the  student  upon  tne  comple- 
tion o(  this  Allat,  as  it  is  the  most  convenient  work 


of  the  kind  that  has  yet  appeared  ;  and  we  must  add, 
the  very  beautiful  manner  in  which  it  is  ''got  up" 
is  so  creditable  to  the  country  as  to  be  fluttering 
to  our  national  pride. — American  Medical  Journal. 


SHARPEY  (WILLIAM),   M.  D.,   JONES   QUAIN,   M.  D.,   AND 
RICHARD   QUAIN,    F.  R.  S.,  &.c. 

HUMAN  ANATOMY.     Revised,  with  Notes  and  Additions,  by  Joseph  Leidt, 

M.  D.,  Professor  ol  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two  large  octavo 
volumes,  extra  cloth,  of  about  thirteen  hundred  pages.     With  over  500  illustrations.    $b  00. 


SOI.I.YONTHE  HUMAN  BRAIN;  its  Structure, 
Physiology,  and  Diseases.  From  the  Seccmd  and 
much  enltirgeU  London  editiim.  In  one  octavi 
volume,  extra  cloth,  of  500  pages,  with  120  wood- 
cuts.    »'2  00. 

SKEY'S  OPERATIVE  SURGERY.    In  one  very 


handsome  octavo  volume,  extra  cloth,  of  over  650 
pages,  with  about  one  hundred  wood-cuts.  S3  25. 
SIMON  >  bK.NKKAJL  PATHOLOGY,  as  conduc- 
ive to  the  Kstablishnjtnt  of  Rational  Principles 
for  the  prevention  ani'  Cure  of  Disease  In  on« 
octavo  volume,  extra  cloth,  of  212  pages.     81  25. 


AND    SCIENTIFIC    PUBLICATIONS. 


27 


STILLE  (ALFRED),    M.D., 

Professor  of  tlie  Theory  and  Practice  of  Medicine  in  the  University  of  Pennsylvania. 

THERAPEUTICS  AND  MATERIA  MEDIGA;  a  Systematic  Treatise  on  the 

Action  and  Us-eis  of  Medic-iiml  Agents,  including  their  Description  and  History.  Second  Edition, 
tliofonghly  revised.  In  two  large  and  liandsonie  octavo  volumes.  (In  Press.) 
This  work  is  designed  especially  for  the  student  and  practitioner  of  medicine,  and  treats  the  VRrious 
articles  of  the  Materia  Medica  from  the  point  of  view  of  the  bedside,  and  not  of  the  shop  or  of  the 
leciure-rooin.  While  thus  endeavoring  to  give  all  practical  information  likely  to  be  useful  with 
respect  to  the  employment  of  special  remedies  in  special  all'eclions,  and  the  results  to  be  anticipated 
from  their  adniinistrat'on,  a  copious  IncJex  ot  Diseases  and  their  Remedies  renders  the  work  emi- 
iienily  fitted  for  reference  by  showing  at  a  glance  the  difTerent  means  which  have  been  e(nployed, 
and  enabling  the  practitioner  to  extend  his  resources  in  dillicult  cates  with  all  that  the  experience 
ol  ihe  profession  has  suggested. 

The  speedy  demand  for  another  edition  of  this  work  shows  that  it  has  acceptably  filled  an  acknow- 
ledged want      No  txerlion  of  the  author  will  be  wanting  to  render  it  worthy  a  continuance  of  the 
favor  with  which  it  has  been  received,  vi'hile  an  al'era'ioii  in  the  typographical  arrangement  will 
accommjdate  the  addi;ions  without  increasing  unduly  the  size  of  the  volumes. 
Rarely,  indeed,  have  we  had  submitted  to  us  ^  I  tinned,  Stille.     His  great  work  on  "  Materia  Medi- 


work  on  medicine  so  ponderous  in  its  dimensions 
as  that  now  before  us,  and  yet  so  fascinating  in  its 
CoiUenrs.  \i  is,  therefore,  with  a  peculiar  gratiti- 
c  ition  that  we  recognize  in  Dr.  Slille  tlie  posses- 
sion of  many  of  those  more  distinguished  qualifica- 
tions which  entitle  him  to  appriit)ation,  and  which 
iiistify  him  in  coming  before  his  medical  brethren 
MS  an  instructor,  a  compreliensive  knowledge, 
tested  by  a  sound  and  penetrating  judgment,  joined 
to  a  love  of  progress- which  a  discriminating  spirit 
of  inquiry  has  tempered  so  as  to  accept  nothing  new 
because  it  is  new,  and  abandon  nothing  old  because 
it  is  old,  but  which  estimates  either  aetorcing  to  its 
relations  to  a  just  logic  and  experience — manifests 
itself  everywiiere,  and  gives  to  the  guidance  of  the 
author  all  'lie  assurance  of  safety  which  the  diffi- 
culties of  his  sub/ect  can  allow.  In  couclusKm,  we 
earnestly  advise  our  readers  to  ascertain  for  them- 
selves, by  a  study  of  Dr.  Stilfe's  volumes,  the  great 


ca  and  Tnerapeutics,"  published  last  year,  in  two 
octavo  volumes,  of  some  sixteen  hundred  pages, 
while  it  embodies  thairesults  of  the  labor  of  ottiera 
up  to  tne  time  of  publication,  is  enriched  with  a 
great  amount  of  original  ohservaticm  and  research. 
We  would  draw  attention,  by  the  way,  to  the  very 
convenient  mode  in  wliich  the  Index  is  arranged  ia 
this  work.  There  is  firstan  ■'  Ir  dex  of  Remedies  ;' 
next  an  "Index  of  Diseases  and  their  Remedies." 
Such  an  arrangement  of  tlie  Indices,  in  our  opinion, 
greatly  enhances  the  practical  value  of  books  of  this 
kind.  In  tedious,  obstinate  cases  of  disease,  where 
we  have  to  try  one  remedy  after  another  until  our 
stock  is  pretty  nearly  exhausted,  and  we  are  almost 
driven  to  our  wit's  end,  such  an  index  as  the  second 
of  the  two  just  mentioned,  is  precisely  what  we 
want. — London  Med.  Timesand  Gazette,  April,  1861. 
We  think  this  work  will  do  much  to  obviate  the 
,  ...         .    r  .u       .  r.  p    1      -1  reluctance  to  a  thorough  investigation  of  this  branch 

y:*il''„t°   wi'^l'^.f., "  „i!!.f..!i'.!'"t!  'i  ,r„"!.'!f!*!..?.t. ''"J     "f  seientihc  study,  fo?  in  llie  wide  range  of  meuical 
,..  „  ,...,„,  »,.     |jtf.fH{ure  treasured  in  the  English  lung  ue,  we  shall 

hardly  find  a  work  written  in  a  style  more  clear  and 
simple.  Conveying  forcibly  the  facts  taught,  and  yet 
free  from  turgidity  and  redundancy .  There  is  a  las- 
cination  in  its  pages  that  wfll  insure  to  it  a  wide 
popularity  and  attentive  perusal,  and  a  degree  of 
usefulness  not  often  attained  through  the  influence 
01  a  single  work. 


present.  We  have  pleasure  in  referring  rather  t( 
the  ample  treasury  of  undoubted  truths,  ihe  real  and 
assured  conquest  of  medicine,  accumulated  by  Dr. 
Stille  in  his  pages;  and  commend  the  sum  of  his  La- 
bors to  the  attention  of  our  readers,  as  alike  honor- 
able to  our  science,  and  creditable  to  the  zeal,  the 
candor,  and  the  judgment  of  him  who  has  garnered 
the  whole  so  carefully. — Edinburgh.  Med.  Journal. 
The  most  recent  authority  is  the  one  last  rnen- 


SIMPSON  (J.  Y.),   M.  D., 
Professor  of  Midwilery,  &e.,  in  the  University  of  Edinburgh,  &c. 

CLINICAL  LECTURES  ON   THE  DISEASES   OP  WOMEN.     With  nu- 

merous  illustrations.     In  one  handsome  octavo  volume,  of  over  500  pages,  extra  cloth   $3  50 

(Now  Ready,  1863.) 

This  valuable  work  having  passed  through  the  columns  of  "  Th^  Medical  News  and  Library" 
for  1860,  18ol,  and  1862,  is  now  completed,  and  may  be  had  separate  in  one  handsome  volume. 

The  principal  topics  embraced  in  the  Lectures  are  Vesico- Vaginal  Fistula,  Cancer  of  the  Uterus, 
Treatment  of  Care. noma  by  Caustics,  Dysmenorrhtea,  Amenorrhoea,  Closures,  Contractions,  itec, 
of  the  Vagirfa,  Vulvitis,  Causes  of  Death  alter  Surgical  Operations,  Surgical  Fever,  Phlegmasia 
Dolens,  Coccyodinia,  Pelvic  Cellulitis,  Pelvic  Haemaioma,  Spurious  Pregnancy,  Ovarian  Dropsy, 
Ovariotomy,  Cranioclasm,  Diseases  of  the  Fallopian  Tubes,  Puerperal  Mauiaj  Sub-Involution  and 
Super-Involution  of  the  Uterus,  (fee.  &c. 

As  a  series  of  monographs  on  these  important  topics — many  of  which  receive  little  attention 
in  the  ordinary  text-books — elucidated  with  the  extensive  experience  and  readiness  of  resource  lor 
which  Profisssor  Simpi-on  is  so  distinguished,  there  are  tew  practitioners  who  will  not  lind  in  its 
pages  matter  of  the  utmost  importance  in  the  treatment  of  obscure  and  difficult  cases. 


SALTER  (H.    H.),    M.  D. 
ASTHMA;  its  Pathology,  Causes,  Consequences,  and  Treatment, 

8vo.,  extra  cloth      {Just  Ready.)      $2  00 

The  porti(m  of  Dr.  Salter's  work  which  is  devoted 
to  treatment,  is  ot  great  practical  inierescand  value. 
It  would  be  necessary  to  toilow  him  step  by  step 
in  his  remarks,  not  (miy  on  the  medicinal,  but  also 
on  the  dietetic  ai.d  hygienic  treatment  of  the  disease, 
in  oruer  to  convey  a  .iust  notion  oi  tne  practical  value 
of  this  part  of  his  work.     This  our  space  fotbius. 


In  one  vol. 


and  this  we  shall  little  regret,  if,  by  our  silence, 
wc  should  induce  our  readers  to  possess  themselves 
of  the  book  itself;  a  book  which,  without  ooubt,  de- 
serves to  be  ranked  am^ng  tlie  most  valuable  of  re- 
cent ctntributiims  to  the  medical  literature  of  this 
country.  — KanA:ing''s  Abstract,  Janr  ,  1361. 


SLADE   (D.   D,),    M.   D. 
DIPHTHERIA :   its  Nature  and  Treatment,  with  -an  account  of  the  History  of 

its  Prevalence  in  various  countries.     Second  and  revised  edition.     In  one  neat  royal  12mo. 
volume.      {Preparing.)  . 


28 


BLANCHARD    &   LEA'S    MEDICAL 


SARGENT  (F.  W.),   M .  D. 
ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SURGERY. 

New  ediiioii,  wi(h  an  additional  chapter  on  Military  Siirp:ery.  One  handsome  royal  12mo.  vol., 
of  nearly  400  pag-es,  witli  184  wood  cuts.  Extra  cloth,  $1  I't.  {Now  Ready.) 
The  value  of  this  work  a,*  a  handy  and  convenient  manual  for  ^urg-eons  engaged  in  active  duty,  has 
induced  the  publishers  to  render  it  more  cotnpleie  for  those  purposes  by  the  addition  of  a  chapter 
on  gun-shot  woinids  and  other  matters  pe<'uli  ir  to  military  surgery.  In  its  present  form,  there- 
fore, with  no  increa>e  in  price,  it  will  be  found  a  very  cheap  and  convenient  vade-mecum  for  con- 
sultation and  relerence  in  the  daily  exigencies  of  military  as  well   as  civil  practice. 

The  instruction  given  upon  the  suljjpct  of  Bin- 
finging,  is  abme  of  great  value,  and  while  the  author 
mcidesily  pniposes  to  instruct  the  students  of  medi- 
cine, and  the  younger  physicians,  we  will  SHy  tliat 
exptriiDced  ph>sician8  will  obtain  many  exceed- 
ingly valuable  suggestions  by  its  perusal,     it  will 


We  consider  that  no  better  bnolc  could  be  placed 
in  Ihehiincis  of  an  liospital  dresser,  or  the  young  sur- 
geon, whose  education  in  this  respect  lias  not  been 
perfected  Wt  most  cordially  commend  this  volume 
as  one  winch  the  medical  ftudent  should  iiioslcidsi^ 
ly  studv,  to  perfect  himself  in  these  minor  surgical 
operalionb  in  which  ntali.ess  ar.d  dexti  rily  are  to 
much  lequirid,  and  on  which  a  grent  portion  <if  his 
rtputation  iisa  future  surgeon  must  evidently  rest 
And  to  the  surgeon  in  practice  it  must  prove  itself 
a  valuable  volume,  as  instructive  on  many  puints 
which  he  may  have  forgotten. — British  American 
Journal,  May,  1862. 


be  fiiund  one  of  tliemost  Sitisfaetory  manuals  I'or  re- 
ftrence  in  the  field,  or  hospital  yet  published  ;  thor- 
oughly adapted  to  the  wants  of  Military  surgeons, 
and  at  the  same  time  equally  useful  for  rendy  and 
ciniveriient  reference  by  surgecmi  everywhere.— 
Buffalo  Med.  and  Surg.  Journal,  June,  IsGd. 


SMITH   (W.   TYLER),  M.  D., 

Physician  Accoucheur  to  St.  Mary's  Hospital,  &c.  ' 

ON   PARTURITION,    AND   THE    PRINCIPLES    AND   PRACTICE   OF 

OBSTETRICS.     In  one  royal  12mo.  volume,  extra  cloth,  of  400  pages.    $1  25. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PxlTHOLOGY  AND  TREATMENT 

OF  LEUCORKHCEA.     With  numerous  illustrations.    In  one  very  handsome  octavo  volume, 
extra  cloth,  ol  about  250  pages.     $1  75. 

TANNER   (T.    H.),    M.  D., 

Physician  to  the  Hospital  for  Women,  &;c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS. 


To  which    is  added  The  Code   of  Ethics   ol   the  American    Medical   Association. 
American  Edition.     In  one  neat  volume,  small  12mo.,  extra  cloth.     $1  00. 


Second 


TAYLOR  (ALFRED  S.),  M.  D.,  F.  R.  S., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDEMCE.     Fifth  American,  from  the  seventh  improved 

an<  enlarged  London  edition.  With  Notes  and  References  to  American  Decisions,  by  Edward 
Hartshorne,M.  IJ.  In  one  large  8vo.  volume  extra  cloth,  of  over  700  pages.  $.3  50. 
This  standard  work  having  had  the  advantage  of  two  revisions  at  the  hands  of  the  author  since 
the  appearance  of  the  last  American  edition,  will  be  found  thoroughly  revised  and  brought  up  com- 
pletely to  the  present  stale  of  the  science.  As  a  work  of  auihoriiy,  it  must  therefore  maintain  its 
position,  both  as  a  text-book  tor  the  student,  and  a  compendious  treatise  to  v^'hich  the  practitioner 
can  at  all  times  reter  in  cases  of  doubt  or  dilticulty. 

American  and  British  legal  mpdicine.  It  should  be 
ill  the  possession  of  every  physician,  Rs  ihe  subject 
IS  ore  of  greai  and  increasing  importance  to  the 
public  as  well  as  to  the  profession.— Si.  Louts  Med. 
and  Surg.  Journal. 

This  work  of  Dr.  Taylor's  is  generally  acknow- 
ledged to  be  one  of  the  ablest  extaiu  on  the  subject 
of  medical  jurisprudence.  It  is  certainly  km  of  the 
most  ailractive  oo  iKs  that  we  have  met  wiih  ;  sup- 
l)l>ing  so  much  boih  to  interest  and  instruct,  that 
we  Uo  not  hesitate  to  athriii  that  afier  havuig  once 
Commenced  us  jierusal,  tew  coulil  be  prevailed  upon 
to  OlsibI  before  completing  it.  In  ihe  last  Limuon 
edition,  all  the  newly  observed  and  accurately  re- 
corued  facis  liave  been  inserted,  in'^ludiug  much 
that  lb  rtccui.  of  Chemical,  Microceojiical,  and  Pa- 
thological   research,   besidi  s  pjipers   on    numerous 

siibjei  ts  never  before  published VharUston  Med. 

Journal  and  Review. 

JSK    THE   SAME    AUTHOR. 

ON  POISONS,  IN  RELATiOiN  10   MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Second  American,  from  a  .second  and  revised  London  edition.     In  one  lar<'e 
octavo  volume,  ol  755  pages,  extra  cloth.     $4  00.  " 

Mr.  Taylor's  position  a>  the  leading  medical  jurist  of  England,  has  conferred  on  him  extraordi- 
nary advantages  in  acqiririiig  experience  in  lhe>e  subject?,  nearly  all  cases  of  moiiierii  being 
referred  to  him  lor  exominaiion,  as  an  expert  whose  loiimony  is  generally  accepted  as  (inal. 
The  results  of  his  labors,  theieluie,  as  galliered  togelher  in  this  volume,  carelully  weighed  and 
sined,  and  piesenlcd  in  the  vleai  and  inlclllgible  >iyle  lor  which  he  is  noted,  may  be'^received 
as  an  acknowledged  authority,  and  a>  a  guide  to  be  (ollowed  with  implicit  coiilideuce. 

BY  THE  SAME  AUTHOR  AND  WM  BRANDE. 

CHEMISTRY.     In  one  volume  hvo.     See  "liiiANUK,"  p.  6. 


No  work  upon  the  subjeci  can  be  put  into  iiie 
hands  of  students  either  of  law  or  medicine  which 
will  engage  them  more  closely  or  profitably;  and 
none  could  be  oflered  to  the  busy  practitioner  ol 
either  calling,  for  the  purpose  ot  casual  or  hasty 
reference,  that  would  be  more  likely  toatlord  tlie  aiu 
desired.  We  therefore  recouin:eiul  it  as  the  best  and 
safest  manual  for  daily  use. — American  Journal  oj 
Medical  Sciences. 

It  is  not  excess  of  praise  to  say  that  the  volumt 
before  us  is  the  very  best  treatise  exiant  on  Medical 
Jurisprudence  In  saving  this,  we  do  not  wish  t< 
be  understood  as  detraelmg  from  tiie  merits  of  tin 
excellent  works  of  Beck,  Ryan,  Traill,  Oiuy,  ano 
others;  but  in  interest  and  value  we  llnnk  it  musi 
be  conceded  that  Taylor  is  superior  to  anythins!  tliai 
has  preceded  it. — iV.  W.  Medirni  nno  Svrg.  lovrttnl 

It  is  at  once  comprehensive  and  eminently  prac- 
tical, and  by  universctl  consent  ftanus  at  the  lieau  of 

BV 


AND    SCIENTIFIC    PUBLICATIONS.  29 

TODD  (ROBERT  BENTLEY),  M.  D.,  F.  R.  S., 

Professor  of  Physiology  in  King's  College,  London;  and 

WILLIAM   BOWMAN,  F.  R,  S., 

Demonstrator  of  Anatomy  in  King's  College,  London. 

THE  PHYSIOLOGICAL  ANATOMY  ANI>  PHYSIOLOGY  OF  MAN.    With 

about  three  hundred  large  and  beautitui  illustrations  on  wood.     Complete  in  one  large  octavo 
volume,  of  950  pages,  extra  cloth.     Price  $4  75. 


Itis  more  eoncise  than  Carpenter'sPrinciples,and 
more  modern  than  the  accessible  edition  of  Mailer's 
Elements;  its  details  are  brief,  but  suffieiei  t;  its 
desenplions  vivid  ;  its  illustrations  exact  and  copi- 
ous ;  and  its  language  terse  and  perspicuous. — 
Charleston  Med.  Journal. 


A  magnificent  contribution  to  British  medicine, 
and  the  American  physician  who  shall  fail  to  peruse 
it,  will  have  failed  to  read  one  of  the  most  instruc- 
tive books  of  the  nineteenth  century. — N.  O.  Med. 
%nd  Surg.  Journal. 


TODD  (R.   B.)     M.  D.,    F.  R.  S.,   &.c. 
CLINICAL  LECTURES  ON  CERTAIN  DISEASES  OF  THE  URINARY 

ORGANS  AND  ON  DROPSIES.    In  one  oclavo  volume,  284  pages,  extra  cloth.     $2  00. 

BY  THE  SAME  AUTHOR. 

CLINICAL  LECTURES  ON  CERTAIN  ACUTE  DISEASES.     In  one  neat 

octavo  volume,  of  320  pages,  extra  cloth.     $2  00. 


TOYNBEE  (JOSEPH),   F.  R.  S., 

Aural  Surgeon  to,  and  Lecturer  on  Surgery  at,  St.  Mary's  HospitaL 

A  PRACTICAL  TREATISE  ON  DISEASES   OF   THE   EAR;   their  Disg- 

nosis.  Pathology,  and  Treatment.     Illustrated  with  one  hundred  engravings  on  wood.    In  one 
very  handsome  octavo  volume,  extra  cloth,  43  50. 


The  v/ork  is  a  model  (if  its  kind,  and  f  very  page 
and  paragraph  oi  it  are  worthy  of  the  most  thorough 
Btudy.  Considered  all  in  all — as  an  originiil  work, 
well  written,  philosophically  eliiborated,  and  happi- 
ly illustrated  with  cases  and  drawings— it  is  by  far 
the  ablest  monograph  that  has  ever  appeared  on  the 
anatomy  and  diseases  of  the  ear,  and  one  of  the  must 
valuable  conLributions  to  theart  and  science  of  sur- 
gery in  the  nineteenth  century. — iV.  Amer.  Medico- 
Chirurg    Kecieio,  Sept.  I8G0. 

■  We  are  speaking  \vithin  the  limits  of  modest  ac- 
knowledgment, and  with  a  sincere  and  unbiassed 
judgment,  when  we  affirm  that  as  a  treatise  on  Aural 


Surgery,  itis  without  a  rival  in  our  language  or  any 
other. —  Chnrlxston  Med.  Journ  and  Rev.,  Sept.  ISCO. 
The  work  of  Mr.  Toynbet  is  undoubtedly,  upon 
the  whole  the  most  valuable  producdon  of  tne  kind 
in  any  language.  The  author  has  long  oeen  known 
by  his  nuMierous  monographs  upon  subjects  con- 
nected with  diseases  of  ihe  ear,  and  is  now  regarded 
as  the  highest  authori'y  on  most,  points  \p  his  de- 
partment of  science.  Mr  Tuynbee's  work,  as  we 
have  already  said,  is  undoubteuiy  the  most  reliable 
guide  for  the  study  of  tlie  diseases  of  the  tar  in  any 
1  inguage,  and  should  be  in  the  library  of  every  phy- 
sician.—C/iJcag-o  Med.  Journal,  Jaiy,  1860. 


WILLIAMS  (C.   J.   B.),    M.D.,    F.  R.  S., 

Professor  of  Clinical  Medicine  in  University  College,  London,  &c. 

.PRINCIPLES  OP  MEDICINE.     An  Elementaiy  View  of  the  Causes,  Nature, 

Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  briei  remarks  on  Hygienics,  or  the  pre- 
servation of  health.  A  new  American,  from  the  third  and  revised  London  edition.  In  one  octavo 
volume,  extra  cloth,  ol  about  500  pages.      Si  25.     (Now  Ready.) 

WHAT    TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER    DEATH,    IN    MEDICAL   CASES. 

.    Publishedundertheauthority  of  the  LondonSociety  for  Medical  Observation.     Anew  American, 
from  the  second  and  revised  Londoii  edition.    In  one  very  handsome  volume,  royal  12mo.,  extra 
cloth.     $1  00. 
To  the  observer  who  prefers  accuracy  to  blunders  I      One  of  the  finest  aids  to  a  young  practitioner  we 

and  precision  to  carelessness,  tliis  little  book  is  in-    have  ever  seen. — Ptninsular  Journal  of  Mtdicin*. 

valuable. — N.  H.  Journal  of  Medicin*.  I 


WALSHE  (W.    H.),   M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London,  &c. 

A  PRACTICAL   TREATISE  ON  DISEASES  OP  THE  LUNGS;  including 

the  Principles  o(  Physical  Diagnosis.  Third  American,  from  the  third  revised  and  much  en- 
larged Lontton  edition.  In  one  vol.  octavo,  of  4b8  pages  extra  cloth  $2  .50. 
The  present  edition  has  been  carefully  revis^ed  and  much  enlarged,  and  may  be  said  in  the  main 
to  be  rewritten.  Descriptions  of  several  diseases,  previou-ly  omitted,  are  now  introduced;  an 
effort  has  been  made  to  bring  the  description  of  anatomical  characters  to  the  level  of  the  wants  of 
the  praciical  physician;  and  the  diagnosis  and  prognosis  of  each  complaint  are  more  completely 
considered.  The  seciions  on  Treatment  and  the  Appendix  have,  e^pecially,  been  largely  ex- 
tended.— Author'' s  Preface. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  THE  HEART  AND 

GREAT  VESSELS,  including  the  Principles  of  Physical  Diagnosis.     Third  American,  from  the 

third  revised  and  much  enlarged  London  edition.     In  one  handsome  octavo  volume  of  420  pages, 

extra  cloth.     %t  50. 

The  present  edition  has  been  carefully  revised  ;  much  new  matter  has  been  added,  and  the  entire 
work  in  a  measure  remodelled.  Numerous  tacts  and  discussions,  more  or  less  completely  novel, 
will  be  found  in  the  description  of  tae  principles  ot  physical  diagnosis;  but  the  chiel  additions  have 
been  made  in  the  practical  portions  of  the  book.  Several  atieclions,  of  which  little  or  no  account 
had  been  given  in  tlie  previous  editions,  are  now  treated  of  in  detail. — Author^s  Preface. 


30 


BLANCHARD   &    LEA'S    MEDICAL 


Ne-w  and  much  enlarged  edition. 

WATSON    (VhOMAS),    M.D.,    (fee, 

Late  Phygician  to  the  Middlesex  Hospital,  &c. 

LECTURES    ON    THE    PRINCIPLES    AND    PRACTICE   OF   PHYSIC. 

Delivered  at  King-'s  College,  London.     A  new  Ameru-an,  frora  the  last  revised  and  enlarged 

English  edition,  with  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of"  A  Practical  Treatise 

on  the  Diseases  of'Children,"  &c.     VVilh  one  hundred  and  eighty. five  illustrations  on  wood.     In 

one  very  large  and  handsome  volume,  imperial  octavo,  of  over  1200  closely  printed  pages  in 

small  type;  exlra  cloth,  $f>  00;  strongly  bound  in  leather,  with  raised  bands,  $6  00. 

That  the  high  reputation  of  this  work  might  be  fully  maintained,  the  author  has  subjected  it  to  a 

thorough  revision;  every  portion  has  been  examined  with  the  aid  of  the  most  recent  researches 

in  pathology,  and  the  results  of  modern  investigations  in  both  theoretical  and  practical  subjects 

have  been  carefully  weighed  and  embodied  throughout  its  pages.     The  watchful  scrutiny  of  the 

editor  has  likewise  introduced  whatever  possesses  immediate  importance  Co  the  American  physician 

in  relation  to  diseases  incident  to  our  climate  which  are  little  known  in  England,  as  well  as  those 

points  in  which  experience  here  has  led  to  difierent  modesof  practice  ;  and  he  has  also  added  largely 

to  the  series  of  illustrations,  believing  that  in  this  manner  valuable  assistance  may  be  conveyed  to 

the  student  in  elucidating  the  text.     The  work  will,  therefore,  be  found  thoroughly  on  a  level  wj^h 

the  most  advanced  state  of  medical  science  on  both  sides  of  the  Atlantic. 

The  additions  which  the  work  has  received  are  shown  by  the  tact  that  notwithstanding  an  en- 
largement in  the  size  of  the  page,  more  than  two  hundred  additional  pages  have  been  necessary 
to  accommodate  the  two  large  volumes  of  the  London  edition  (which  sells  at  ten  dollars),  within 
the  Compass  of  a  single  volume,  and  in  its  present  form  it  contains  the  matter  of  at  least  three 
ordinary  octavos.  Believing  it  to  be  a  work  which  should  lie  on  the  table  of  every  physician,  and 
be  in  the  hands  of  every  student,  the  publishers  have  put  it  at  a  price  within  the  reach  of  all,  making 
it  one  of  the  cheapest  books  as  yet  presented  to  tlie  American  profession,  while  at  the  same  time 
the  beauty  of  its  mechanical  execution  renders  it  an  exceedingly  attractive  volume. 


The  fourth  edition  now  appears,  so  carefully  re- 
vised, as  to  add  considerably  to  the  value  of  a  book 
alieady  acknowledged,  wherever  the  English  lan- 
guage is  read,  to  be  beyond  all  comparison  the  best 
sjsferaatic  work  on  the  Principles  and  Practice  of 
Physic  in  the  whole  range  of  medical  literatare. 
Every  lecture  contains  proof  of  the  extreme  anxiety 
of  the  author  to  keep  pace  with  ihe  advancing  know- 
ledge of 'the  day  One  scarcely  linows  whether 
to  admire  most  the  pure,  simple,  forcible  English — 
the  vast  amount  of  useful  practical  information 
condensed  into  the  Lectures— or  the  manly,  kind- 
hearted,  unassuming  character  of  the  lecturer  shin- 
ing through  his  work.— Lund.  Med.  Times. 

Thus  these  admirable  volumes  come  before  the 
profession  in  their  fourth  edition,  abounding  in  those 
distinguished  attributes  of  moderation,  judgment, 
erudite  cultivation,  clearness,  and  eloquence,  with 
which  they  were  from  the  first  invested,  but  yet 
richer  than  before  in  the  results  of  more  prolonged 
observation,  and  in  the  able  appreciation  of  the 
latest  advances  in  pathology  and  medicine  by  one 
of  the  most  profound  medical  thinkers  of  the  day. — 
London  Lancet. 


The  lecturer's  skill,  his  wisdom,  his  learning, are 
equalled  by  the  ease  of  his  graceful  diction,  his  elo- 
quence, and  the  far  higher  qualities  of  candor,  of 
courtesy,  of  modesty,  and  of  generous  appreciation 
of  merit  in  others. — N.  A.  Med.-Chir   Review. 

Watson's  unrivalled,  perhaps  unapproachable 
work  on  Practice — the  copious  additions  made  to 
which  (the  fourth  edition)  have  given  it  all  the  no- 
velty and  much  of  the  interest  of  a  new  book. — 
Charleston  Med.  Journal. 

Lecturers,  practitioners,  and  students  of  medicine 
w^ill  equally  hail  the  reappearance  of  the  work  of 
Dr.  Watson  in  the  form  of  a  new — a  fourth — edition. 
We  merely  do  justice  to  our  own  feelings,  and,  we 
are  sure,  of  the  whole  profession,  if  we  thank  him 
for  having,  in  the  trouble  and  turmoil  of  a  large 
practice,  made  leisure  to  supply  the  hiatus  caused 
by  the  exhaustion  of  the  third  edition.  For  Dr. 
Watson  has  not  merely  caused  the  lectures  to  be 
reprinted,  but  scattered  through  the  whole  work  we 
find  additions  or  alterations  which  prove  that  the 
author  has  in  every  way  sought  to  bring  up  his  teach- 
ings to  the  level  of  the  most  recent  acquisitions  in 
science. — Brit,  and  For,  Medico-Chir. Review. 


New  and  much  enlarged  edition. 

WILSON    (ERASMUS),   F.  R.  S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.     A  new  and  re- 

vised  American,  from  the  last  and  enlarged  English  Edition.  Edited  by  W.  H.  GoBRECH^r,  AL  D., 
Proliissor  of  Anatomy  in  the  Pennsylvania  Medical  College,  &c.  Illustrated  with  three  hundred 
and  ninety-seven  engravings  on  wood.  In  one  large  and  exquisitely  printed  octavo  volume,  of 
over  600  large  pages;  extra  cloth,  $3  75. 

The  publishers  trust  that  the  well  earned  reputation  so  long  enjoyed  by  this  work  will  be  more, 
than  maintained  by  the  present  edition.  Besides  a  very  thorough  revision  by  the  author,  it  has  been 
most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  introducing 
everything  which  increased  experience  in  its  use  lias  suggested  as  desirable  to  render  it  a  complete 
text-book  lor  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Anatomy.  The 
amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  tact  that  the  present 
edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type  and  an  enlarged 
page  requisite  to  keep  the  volume  within  a  convenient  size.  The  editor  has  exeicised  the  utmost 
caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased  the  number  of'  illustra- 
tions, of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition  than  iii  the  last,  thus 
bringing  distinctly  before  theeye  of  the  student  everything  of  interest  or  importance. 

It  may  be  recommended  to  the  student  as  no  less 
distinguished  by  its  accuracy  and  clearness  of  de- 
scription tiian  by  its  typographical  elegance.  The 
wood-cuts  are  exquisite. — Brit,  and  For.  Medical 
Review. 


An  elegant  edition  of  one  of  the  most  useful  and 
accurate  systems  of  anatomical  science  which  lias 
been  issued  from  the  press  The  illustrations  are 
really  beautiful.  In  its  style  the  work  is  extremely 
concise  and  intelligible.  No  one  can  possibly  lake 
np  this  volume  without  being  struck  with  the  great  ]  Southern  Med.  and  Surg.  Journal. 


beauty  of  its  mechanical  execution,  and  the  clear- 
ness of  the  descriptions  which  it  contains  is  equally 
evident.  Let  students,  by  all  means  examine  tue 
claims  of  this  work  on  their  notice,  before  they  pur- 
chase a  text-book  of  the  vitally  important  science 
which  this  volume  bo  fully  and  easily  unfolds. — 
Lancet. 

We  regard  it  as  the  best  gystem  now  extant  for 

students. —  Western  Lancet. 

It  therefore  receives  our  higheBtcomraendation. — 


AND   SCIENTIFIC    PUBLICATIONS 


31 


WILSON    (ERASMUS),    F.  R.  S. 
ON  DISEASES   OF   THE   SKIN.     Fifth  Auierican,  from  the  Fifth  enlarged 

London  edition.     In  one  handrome  octavo  volume,  of  nearly  700  larg:e  pages,  with  illustrations 

on  wood,  extra  cloth      $4  OU.     (Noto  Ready,  iVlay,  1863.) 

This  classical  w  ork,  which  for  twenty  years  has  occupied  the  position  of  the  leading  authority 
in  the  English  language  on  its  important  siibject.  has  just  received  athorou<^h  reviMon  at  the  hands 
of  the  author,  and  is  now  pre.-ented  as  embodying  the  results  of  the  latest  inve>ligations  and  expe- 
rience on  all  matters  connected  with  diseases  of  the  skin.  The  increase  in  the  .-ize  of  iha  work 
shows  the  industry  of  the  auihor,  and  his  deierminaiion  that  it  stiall  maintain  the  position  which  it 
has  acquired  as  thoroughly  on  a  level  with  the  most  advanced  condition  of  medical  science. 

A  i>ivf  notices  of  the  last  edition  are  appended. 


The  writings  i)f  Wilson,  upondiscasesof  the  skin, 
are  by  far  tlie  most  scientific  and  practical  that 
have  ever  been  presented  to  the  medical  world  on 
this  subject.  The  presenteUition  isagreat  improve- 
ment on  all  its  predecessors.  To  dwell  upon  all  the 
great  merits  and  high  claims  of  the  work  before  us, 
5erta<irn,  would  mdced  be  an  agreeable  service  ;  it 
■would  be  a  mental  homage  which  we  could  freely 
ofTer,  but  we  should  thus  occupy  an  undue  amount 
of  space  in  this  Journal.  We  will,  howtver  look 
at  some  of  the  more  salient  points  with  which  il 
abounds,  and  which  ma kciiiiicomparauiy  superior  to 
all  other  treatises  on  thesubjecmrilerrnarology  No 
mere  speculative  views  are  allowed  a  place  in  this 
volume,  which,  without  a  doubt  will,  for  a  very  long 
period,  be  acknowledged  as  the  chief  standard  work 
on  dermatology.  The  principles  of  an  enlighiened 
and  rational  therapeia  are  introduced  on  every  ap- 
propriate occasion. — ATTi.Jour.  Med  Science. 

When  the  first  edition  of  this  work  appeared 
about  fourteen  years  ago,  Mr  Erasmus  '\Vils(m  hau 
already  given  some  yeais  to  the  study  of  Diseases 
of  the  Skin,  and  he  then  expressed  his  intention  of 
devoting  his  fuiure  ife  to  the  elucidation  of  this 
branch  of  I\Iedical  Science  In  the  present  edition 
Mr.  Wilson  prtpents  ns  with  the  results  of  his  ma 
tured  experirnce,  and  we  have  now  before  us  not 
merely  a  reprint  of  his  former  publi''ati(ms,  but  an 
entirely  new  and  rewritten  volume.  Thus,  the  whole 
history  ot  the  ai.seases  affecting  ihe  skin,  whether 
they  originate  in  that  structure  urare  the  mere  m mi- 
festations  of  derangement  of  iniernal  organs,  is 
brought  under  notice, and  the  bonk  includes  a  mass 
of  Uifiinnation  which  is  spread  over  a  gieat  part  of 
the  domainof  Medical  and  Surgical  Pathob'gy.  We 
can  safely  recommend  it  to  the  proiessioii  as  the 
best  work  on  the  subject  now  in  existence  in  the  En- 
glish language. — London  Med.  Times  and  Gazette 


No  matter  what  other  treatises  may  be  in  the  libra- 
ry of  tlie  medical  attendant,  he  needs  the  clear  and 
sugge.stive  counsels  of  Wilson,  who  is  thoroughly 
posied  up  on  all  subjects  connected  with  cutaneous 
pathology.  We  hare,  it  is  very  true,  othe-.  valuable 
works  on  the  maladies  that  invade  the  -tin;  but, 
compared  with  the  volume  under  consideration,  they 
are  certainly  to  be  regarded  as  inferior  lights  iu  guid- 
ing tlie  judgment  of  the  medical  uia.ti.—Boiton  Med. 
and  Surg.  Journal,  Oct.  1S.J7. 

•  The  author  adopts  a  simple  and  entertaining  style. 
He  strives  to  clear  away  the  complications  of  his 
subject,  and  has  thus  produced  a  book  tilled  with  a 
vast  amount  of  information,  in  a  form  so  agreeable 
as  to  make  it  pleasant  j-eading,  even  to  the  uninitiated. 
More  especially  does  it  deserve  our  praise  because  of 
its  beautiful  and  complete  atlas,  which  the  Aniericaa 
publishers  have  successfully  imitated  from  the  origi- 
nal plates.  We  pronuunce  them  by  far  the  best  imi- 
tations of  nature  yet  publi.--hed  in  our  country.  With 
Ihe  text-book  and  atlas  at  hand,  the  diagnosis  is  ren- 
dered easy  and  accurate,  and  the  practitioner  feels 
himself  safe  in  his  treatment.  We  will  add  that  this 
work,  although  it  must  have  been  very  expensive  to 
the  pulTlishers,  is  not  high  priced.  There  is  no  rea- 
son, then,  to  prevent  every  physician  from  obtaining 
a  work  of  such  importance,  and  one  which  will  save 
him  both  labor  and  perplexity. —  Va.  Med.  Journal. 

As  a  practical  guide  to  the  clas.sjfication,  diaguosls, 
and  treatment  of  the  diseases  of  the  skin,  the  book  is 
complete.  We  know  nothing,  considered  in  this  as- 
pect, better  in  our  language  ;  it  is  a  safe  authority  ou 
all  the  ordinary  matters  which,  in  this  range  of  dis- 
eases, engage  the  practitioner's  attention,  and  pos- 
sesses the  high  quality  —  unknown,  we  i)elieve  to 
every  older  manual,  of  being  on  a  level  with  science's 
high-watermark;  a  sound  book  of  practice. — Lotuion 
Med.  Times. 


ALSO,   NOW  READY, 

A  SERIES  OF  PLATES  ILLUSTRATINQ  WILSON  ON  DISEASES   OP 

THE  SKIN;  consisting  of  twenty  beautifully  executed  plates,  of  which  thirteen  are  exquisitely 
colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin,  and  containing  accurate  re- 
presentations of  about  one  hundred  varieties  of  disease,  most  of  them  the  size  of  nature.     Price 
in  cloth.     $4  50. 
In  beauty  ol  drawing  and  accuracy  and  finish  of  coloring  these  plates  will  b^  found  equal  to 

anything  of  the  kind  as  yet  issued  in  this  country.    Tne  value  of  the  new  edition  is  enhanced  by 

an  additional  colored  plate. 

The  plates  by  which  this  edition  is  aecompanied 

leavcjiothing  to  be  desired,  so  far  as  excellence  of 

delineation  and  perfect  accuracy  of  illustration  are 

concerned. — Medico-Chirureical  Review. 


We  have  already  expressed  our  high  appreciation 
of  Mr.  Wilson's   treatise  on   Diseases  of  the  Skin. 


The  plates  are  comprised  in  a  separate  volume, 
which  we  counsel  all  those  who  possess  the  text  to 
purahase.  It  is  a  beautiful  specimen  of  color  print- 
ing, and  the  repiesentations  of  the  various  forms  of 
skin  disease  are  as  faithful  as  is  possible  in  plates 
of  the  size.— Boston  Med.  and  6urg.  Journal,  April 
S,  185S.  ^ 


Ol  these  platesit  isimpossible  to  speak  too  highly 
The  representations  of  the  various  forms  of  cutane- 
ous disease  are  singularly  accurate,  and  the  color- 
ing exceeds  almost  anything  we  have  met  with. — 
British  and  Foreign  \ledital  Review. 

Also,  the  TEXT  and  PLATES  done  up  in  one  hands  )me  volume,  extra  cloth,  price  fS  GO. 

BY  THE  SAME  AUTHOR. 

THE    DISSECTOR'S  MANUAL;  or,  Practical  and  Surgical  Anatomy.     Third 

American,  from  the  last  revised  and  enlarged  English  edition.  Modified  and  rearranged,  by 
William  Hunt,  iVL.  D.,  Ueinonstraior  of  Anatomy  in  the  University  ol  Pennsylvania.  In  one 
large  and  handsome  royal  12mo.  volume,  extra  cloth,  of  5S2  pages,  with  104  illustrations      $2  00 

BY    the   same    author 

ON    CONSTITUTIONAL    aND    HEKEDITARY    SYPHILIS,   AND    ON 

SYPHILITIC  ERUPTIONS.  In  one  small  octavo  volume,  extra  cloth,  beautifully  printed,  with 
four  exquisite  colored  plates,  presenting  more  than  thirty  varieties  ol  syphilitic  eruptions.  $2  25 

BY   the  same   author. 

HEALTHY  SKINj  A  Popular  Treatise  ou  the  Skin  and  Hair,  their  Preserva- 
tion and  Management.  Second  American,  from  the  fourth  London  edition.  One  neat  volume, 
royal  12mo. 5  extra  cloth,  of  about  300  pages,  with  numerous  illustrations.  $1  00;  paper  cover, 
75  cents. 


32 


BLANCHARD   &    LEA'S    MEDICAL    PUBLICATIONS. 


WINSLOW    (FORBES),  M.D.,   D.  C.  L.,   &.c. 
ON  OBSCURE  DISExVSES  OF  THE  BKATN  AND  DISORDERS  OF  THE 

MIND;  ilieir  inc-ipii'iU  Sympiom«,  Puihokgy, 
handsome  octavo  volume,  of  nearly  GOO  pages, 

We  close  this  brief  and  necessarily  very  imperfect 
notice  of  Dr.  Winslow's  ^rcal  and  classical  work, 
by  exuresbing  our  conviction  thai  it  is  long  since  8o 
iiiipoSknt  and  beautifully  written  a  volume  has  is- 
sued from  the  British  medical  pre^s. — JJuilitiMtd. 
J'ress,  July  --'5,  1S60. 

We  honestly  believe  this  to  be  the  best  book  of  the 
season.—  banking's  Abstract,  July,  IstiO. 

The  'atter  portion  of  Dr.  Wmslovv's  work  is  ex- 
clusively devoted  to  the  cunsideraiioa  of  Cerebral 


Diagnosis,  Treatment,  and  Prophylaxis.    la  one 
extra  cloth.     §3  50. 

Pathology.  It  completely  exhausts  the  subject,  in 
liie  same  manner  as  the  previous  seventeen  chapters 
relating  to  morbid  psyjhical  phenomena  left  nothing 
unnoticed  in  reference  to  ihe  menial  symptoms  pre- 
monitory of  cerebral  disease.  It  is  impossible  to 
overrate  the  benefits  likely  to  result  from  a  general 
perusal  of  Dr.  Winslow's  valuujle  and  deeply  in- 
teresting work. — London  Lancet,  June  23,  IbtiO. 

It  contains  an  immense  mass  of  information.— 
Brit,  anil  For.  Mtd.-Chir.  Revuw,  Oct.  lt:60. 


WEST   (CHARLES),    M.  D., 

Accoucheur  to  and  Lecturer  on  Midwifery  at  St.  Bartholomew's  Hospital,  Physician  to  the  Hospital  for 

Sick  Cflildren,  ice. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.    Second  American,  from  the 

second   London  edition.     In  one   handsome  octavo  volume,  extra  cloth,  oi  about  500  pages ; 
price  $3  00. 

*jt*  Gentlemen  who  received  the  first  portion,  as  issued  in  the  "Medical  News  and  Library,"  can 
DOW  complete  their  copies  by  procuring  Part  II,  being  page  309  to  end,  with  Index,  Title  matter, 
&c.,  8vo.,  cloth,  price  f  1. 

\A'^emustnow  conclude  this  hastily  written  sketch  i      We  gladly  recommend  his  Lectures  as  in  thehigh- 
with  the  confiilent  assurance  to  our  readers  that  the  :  est  degree  instructive  to  all  who  are  interested  in 
work  will  well  repay  perusal.     The  conscientious,    obstetric  priictice. — London  Lancet. 
painstaking,  practical  physician  isapparenton  every        Happy  in  his  simplicity  of  manner,  and  moderate 
page. — N.  Y.  Journal  of  Medicine.  jn  jug  expression  of  opinion,  the  author  is  a  sound 

We  know  of  no  treatise  of  the  kind  so  complete    reasoner  and  a  good  piaqtitioner,  and  his  book  la 


and  yet  so  compact.— CAicag-o  Med.  Jour. 

A  fairer,  more  honest,  more  earnest,  and  more  re- 
liable investigator  of  the  many  diseases  of  women 
and  children  is  not  to  be  found  in  any  country.— 
Southern  Med.  and  Surg.  Journal. 

We  have  to  say  of  it,  briefly  and  decidedly,  that 
it  is  the  best  work  on  the  subject  in  any  language  j 
and  that  it  stamps  Dr.  West  as  the /aciie  princept 
of  Sntish  obstetric  authors. — Edinb.  Med.  Journ. 


worthy  of  the  hanusome  garb  iu  which  i{  hai>  ap- 
peared.—  Virginia  Med.  Journal. 

We  must  take  leave  of  Dr.  West's  very  useful 
work,  with  our  coinmendaiion  of  the  clearness  of 
its  style,  and  the  incustry  and  sobriety  of  judgment 
of  whicn  It  gives  evidence. — London  Med   Times. 

Sound  judgment  and  good  sense  pervade  every 
chapcer  of  the  oook.  From  its  perusal  we  nave  de- 
rived unmixed  satisfaction. — Dublin  Quart.  Juum. 


BY    THE  SAME   AUTHOR. 


LECTURES   ON   THE   DISEASES   OF  INFANCY  AND  CHILDHOOD. 

Thud  American,  I'rom  the  Iburth  enlarged  and  improved  London  edition.     In  one  handsome 
octavo  volume,  extra  clotn,  of  about  six.  liundred  anci  fiiiy  pages.     $3  00. 


The  three  forgner  editions  of  the  work  now  before 
ns  have  placed  the  author  in  the  foremost  rank  of 
those  pli)  sicians  who  have  cevoted  special  attention 
to  tiic  diseates  of  early  life  We  attempt  no  ana- 
1)  sis  of  this  edition,  but  may  refer  the  reader  to  some 
of  the  chapters  to  wnicli  the  largest  additions  have 
been  made — those  on  Diphtheria,  Disorders  of  t/ic 
Mind,  and  Idiocy,  for  instance — as  a  prool  that  the 
worK  IS  really  a  neweuition;  not  a  mere  reprint. 
In  its  present  shape  it  will  be  lound  of  the  greatest 
possible  service  in  the  every-day  practice  of  nine- 
tenllis  of  the  profession. — Med.  Times  and  Gazette, 
London,  l3tc.  10,  1SJ9. 

All  things  considi  red.  this  book  of  Dr.  West  is 
by  far  tlie  best  treatise  in  our  language  upon  such 
modiflcutions  of  morbid  action  and  disease  as  are 
wilntbscd  when  we  have  to  deal  with  iulancy  and 
chiluhood.  It  is  true  that  it  confiut's  itself  to  such 
disorders  as  come  wuhin  the  province  of  the  phy- 
sician, and  even  with  lespect  to  these  it  is  unequal. 
as  regards  imuuteuiSE  of  consideration,  and  some 


diseases  it  omits  to  notice  altogether.  But  those 
who  know  anything  of  the  picaent  condition  of 
jicedittlrics  will  reailily  admit  that  it  would  be  next 
to  impossible  to  elfect  more,  or  etfect  it  better,  than 
the  accoucheur  of  St.  Bartholomew's  has  done  m  a 
single  volume.  The  lecture  (XVI.)  upon  llisurctrs 
of  the  Mind  in  chiluren  is  an  admirable  specimen  of 
the  value  ol  the  later  iul'ormation  couve)ed  iu  tne 
Lectures  of  Lit.  Charles  West. — London  Lancet, 
Uct.  22,  1S59. 

Since  the  appearance  of  the  first  edition,  about 
eleven  years  ago,  the  experience  of  the  author  has 
doubU-d ;  so  that,  whereas  the  lectures  at  iirst  were 
founded  on  six  hundred  observations,  and  one  hun- 
dred and  eigmy  dissections  made  among  neatly  four- 
teen tliousaud  children,  they  now  embody  the  results 
of  nine  hundred  observations,  and  two  hundred  and 
eighty -eight  post- mortem  examuiatiousmade  amtmg 
nearly  thirty  thousand  children,  who,  during  tne 
past  twt-Lty  years,  have  been  under  his  care. — 
British  Med.  Journal,  Oct.  1,  ISoU. 


BY  THE  SAME  AUTHOR. 


AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OP  ULCER- 

ATION  OF  THE  Od  IJTLKL    In  one  neat  octavo  volume,  extra  cloth.    «!' 00. 


WHITEHEAD  ON  THE  CAUSES  AND  TREAT- 
.UENT   OF    ABORTION    AWD   STER1HX\. 


Second  American  Edition.    In  ontTolam*,  osta- 
vo  extra  cloth,  pp.  306'.    §2  25. 


mi 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


MAR  2  S  1968 


l\^ 


Form  L9-40m-5,'67(H2161s8)4939 


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